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a - n San Joaquin C lOunty npD, �V <br /> io <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Flo4,Stockton,CA 9520f EB 0 j ?00? MITIGATION <br /> ( (209)468-3449 Fax:(209)468-3433,, eb-.www.sjgov,glgJr''td�ME UNIT IV <br /> '��°�tiVV�tt�t(Uj NTHEA11H <br /> Well Permit Apls ication PERMIT/SERVICES <br /> NON-REFUNDABLE PERW EXPIRES 1 EAR FROSY. DATE ISSUED <br /> Appllral on is hereby made to San Joaquin County for a pemfit to construd ar !r install the work described_ This applicafon is made in corroance with San <br /> Joaquin County aswjogmerk Title,Chapter 94115.3 and the Standards of San I, in County envirorwner"tiealdr Department. <br /> 1 �5� Assessors <br /> WELLL�' tIAS�Lfi�t� "'rte crossstreet J S er city,I.ATNF�c:.�i' Zq, "��� 3L ParaetA <br /> PROPERTY Lot+ .� 45'�­7 <br /> Imo. �' <br /> Ormer tnh+ -_ ,Mf Address _ .,. Zip '�'36MandR---�- � <br /> cdr7coniractnr _lT R_I t-t.�Hrpaaarr �5d7 T* _ I3� scz Pad- z <br /> City-zq, 5�} op►ro <br /> III �:.WY 1kfIZ (fvlg n'32"1 805 1 <br /> Cansudisirt I Sub CrAr ress22-7`) EHcIi,='-ai,Frl Cityt-c�x.tA Lica Phonelt"71�-3`t8"b3L� <br /> GIS Coordinates:X Y .Township Range Section <br /> WORK TO BE P�D: <br /> a NEW WELL I BORING (CPT,GEOPROBE,HYOROPUNCH,HAND-0 UGER,OnIErr) Q DESTRUCTION (choose type below) <br /> OVER-BORE. DIAMETER <br /> 13 SOIL BORING: rn w IS R M w(50 p PRESSURE GROUT <br /> Q,OOW GROUT SPECIFICATIONS <br /> COMMENTS: q <br /> TYPE OF TYPE CONSTR SPKMUM-INS <br /> .' Scj:. VV' I.L 71f�C�i=NEMS .f <br /> Q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE '!. Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASTING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CAsiNG THICKNEss. _ TYPE OF CASING: a STEEL a PVC Q OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT. 5 TREWE TYPE TO BE USED, Q AUGERS a HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUM : Q Yes p No (NOTE IXJL�ui G71=R :E-FALL DEPTH IS 30') <br /> 0 SOIL BORING Q HAND AUGER GROUT"SPECIMA. „, S CC t1¢�t M:=i <br /> 0 OTHER: a OTHERL APPROX.BORING I PTH -25 r0�0 90'- BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASIN PROPOSED (d YES.list spedfKa ions in comment section) <br /> COENTS; I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCE AGREEVENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE�i QUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and {tthe work vAII be done in accordance with San Joaquin <br /> County Ordlna es, We and Regulations,and all appaca Califnnda State Lavin N jVIENrk L <br /> Print Name Date— u�10�0�1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l <br /> WORK PIAN DATED: C <br /> Applimflon Aacapted By <br /> Oats issued a rP o Area <br /> Gnwt irnspection By Date D Final Inspection By Date !3 d __ <br /> Deseuctlon InsperYron By Dale �I <br /> C TENTS 1 CONDITIONS: <br /> i' <br /> ACCOUNTING ONLY: ARM AC# <br /> PE COOI:S FEE IWO At=NT RECI'ITED CIECIC a �! CD BY DATE PEIV=I SERVICE REDUEST a IKMCE <br /> SFW a <br /> C-57, WG---WAIVER— C-57 Letter of AUthori*tion to sign permit_Encroachment doc <br /> E D 29-02401 <br /> G22M <br />