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" 4kn Joaquin County <br /> Environmental Health Department Oc� <br /> SITE <br /> 304 Fast Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209) 468-3449 fax: (209)468-3433 Web: www.sjgov.org/ehd !VP '7 ?00N <br /> UNIT IV <br /> Well Permit Application L_r V,H,pI, ETHE^P�' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> a'E;�miT/,�E:.R1V1 E S <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Cha to 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 131 �3d—G <br /> �� e Assessors <br /> WELL Locatio o Cross Street k", City 5�,���� Zip 5 Zai Parcel# 3 ^236 <br /> 31-,?-.30-6 <br /> PROPERTY <br /> Owner'Pock Address 21a 1 a.s�',�.. n City, ,,p,110.. Zip C A Phone# (tb1k)'j4G-1c1L44. <br /> C-57 ContractorAddress loSI E55eK CityT,•,,ltim.o Zi oaf"Lic# 'SS Phone#(51D�JS-t:`4 S <br /> 11 �J 2{21 (�.l'. E,mrH•, . �1o���k <br /> Consultant/Sub Cntr i?--S , Coco . Address TSt v A, 5 ,; <g 227 City C-r-e-V- Lic# 16 Phone#_giS�93 E 00 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL /BORING (CPT,GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 1,5 0 OVER-BORE. DIAMETER <br /> WELL# 'g "r-- 0 PRESSURE GROUT / <br /> EL*Other GROUT SPECIFICATIONS �?-nj'DjC�'Ku�Z�M�- <br /> COMMENTSAS QXPICK "f% e-s <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AMONITORING A HOLLOW STEM DIA.OF BOREHOLEA" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2 _. <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SGL. 0 O TYPE OF CASING: 0 STEEL `ePVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL r,-e--TREMIE TYPE TO BE USED: 0 AUGERS DQJOSE <br /> 0 AIR SPARGE/OZONE f PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS'Cctw� '.. a,,- j I ,} 4 <br /> OTHER: 0 OTHER _ APPROX. BORING DEPTH SU BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) _ <br /> COMMENTS: <br /> � a <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this ap ication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules-and Re d all applicable California State Laws. <br /> Signed x �L-- Title/Company <br /> -ic <br /> Print Name -C-,r S o n a`u�a�� �ti, /�1�c,40L.. Y L Q > - 5 Date <br /> DEPARTMENT USE OILY <br /> SITE MAP IN UNIT IV FILE, ADDRESS:_ -- <br /> WORK PLAN DATED: t-- - I2"b d <br /> yy� ff `�9 <br /> Application Accepted By 77 � �'� Date Issued `7 d S Area_ <br /> Grout Inspection ByDate 3 cr Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: n t4r'r V, tv S -S S d be r it e Q C16 _. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> a q 1 3 41 jt/ds SR# L�` s``8 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br />