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- an Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton, CA 9 <br /> �- (209)468-3449 Fax: (209)468-3433 Web: www.sjgov,o g e IGATIQN <br /> Well Permit Application AUG 1 .7 20UUNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1!a^ IRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.��TT� <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County EnvirorimenfaF+h� � �nt �in compliance with San <br /> �7 r�` I1 {� epartment. <br /> WELL Location C- l Yf4W�yr1 t�cvnQ Cross StreetlJ tj City.� Oi G](� Zip Assessors <br /> ty P�Parcel#_.. <br /> PROP <br /> MTY <br /> Owner h IAA dadress�{�ult1�T+ <br /> _CitYT42 .. zip. 5U <br /> Pnorte# _ <br /> C-67 ContractorAddres sss� �{+ q - <br /> K'1__ city io v: zip9�571 L;c#71ac? Pnone#707-37y�13�a <br /> Consultant/Sub Crrtr Mr <br /> _J �i1Ji1b� Address �pvl/,Oj Qj, s PL;l C4 I Slv e Z Phane# 530-6 -baa <br /> GIS Coordinates:X Y ' <br /> Township Range Section <br /> M R PE FED; <br /> 'IEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> 1]SOIL BORING# <br /> Q WELL# MW-1 _ [I OVER-BORE. DIAMETER <br /> 11'Other U PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS�� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE �� `1 <br /> I]MULTIPLE CASINGS II MULTI-LEVEL WELL CASING DIA:2 <br /> p EXTRACTION 9 AIR HAMMERIDRIVEN CASING THiCKNESSS ,110 <br /> [J VAPOR TYPE OF CASING:' (1 STEEL ' PVC 0 OTHER; <br /> d MUD ROTARY DEPTH OF GROUT SEAL UTREMIE TYPE TO BE USED: ',AUGERS 0 HOSE <br /> a AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes )ZNo SN TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:� OTHERAPPROXBORING DEPTH t71 <br /> . <br /> °BOLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS; CONDUCTOR CASING PROPOSED_(if.YES,list specifications In comment section) <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT O11 R ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin rC=* <br /> County Ordinances,Rules and Regulations,and all applicable CaliforniaStateLaws. �✓ <br /> Signed x Title/Company 19x0 i y �� <br /> Lf { `r LSC: <br /> Print Name 4 ;r II qq <br /> Date U _0 <br /> DEPARTMENT USE ONLY a•.ft <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 <br /> k <br /> WORK PLAN DATED: S 1,7 —�---�- <br /> Application Accepted ey <br /> Date Issued <br /> Grout Inspection By Dale Z o 7-Final Inspection B <br /> P Y <br /> Destruction Inspection By Date - _ <br /> COMMENTS I CONDITIONS: ) <br /> ACCOUNTING ONLY: AID# <br /> fAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# F SY DATE PERM IT SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57^ WCC WANER� C-57 Letter of Authorization to sign permit-/—E'ncrtiachment do,;_ <br /> EHD 29-02-001 <br /> 6/22/44 <br /> i <br />