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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber•Avenue,3rd Floor, Stockton,CA 95202 z MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd -Z-3gZ UNIT IV <br /> wo Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 720 W, Inkkev Ave Cross Street b A&-,Ih Assessors <br /> City SixE�a/I Zip 4.S20Z Parcel# 137-370-61 <br /> PROPERTYN,,Dc/lePytt,,,,��,,�� A <br /> Owner 4Ae`1dress.� VJ WAw City-<125art ZIp9.S1A2 Phone#2Q S41 457-0 <br /> C-57 Contractor RS S Address22O CityS Zip�Uc#*3� Phone# 3n �� 292y <br /> Consultant/Sub Cntr E✓�hTc�� Address/05 �C City o Lic# Phone# <br /> GIS Coordinates:X Y ,Township RangeSection <br /> WORK TO BE PERFORMED: <br /> 'NEW WELL/BORING ( PT GEOPROBE,HYDROPU 4CH,HAND-AUGER,OTHER) p DESTRUCTION (choose type below) <br /> WELL# RING# 5511-27jb1/-l �1J J'2`( DOVER-BORE. DIAMETER <br /> (]PRESSURE GROUT <br /> a*Other 11 GROUT SPECIFICATIONS <br /> COMMENTS: bVzY\\ -- L0`09 S 61- V46r 5O,!n4 I IP S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Tm�ar t (�y <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGSifMULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS _ -TYPE OF CAST �� � HER: <br /> �NAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE ItiS@D� ^ RS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )ICSOIL BORING a HAND AUGER GROUT SPECIFICATIONS SAAR:0 1 2006 <br /> 0 OTHER: J50THER DPT- APPROX.BORING DEPTH 0 BOLTED TR��A�FlF�IC�� '\B'�OOXIl LLounr {g{TOVE PIPE <br /> CONDUCTOR CASING PROPOSED @Nd1RlJ '-ii'NiW1jbd ' rament section) <br /> COMMENTS: P RMILSERVICES <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 application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed�- Tide/Company �,^t <br /> /i'�)T�� <br /> Pdnt Name'M& G 2'Fx"'- Date 3�61fl0' <br /> i <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: j <br /> Application Accepted By t . v r' Date Issued MA;t7 ZZO a <br /> _ Grout Inspection By1444dwA Z4Date Final Inspection By Date <br /> Destruction Inspection to <br /> COMMENTS I CONDITIONS: Y ( C Nli <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2I10 39 , 001 <br /> s8c O Q , ; 1j of 31Z51AC6 SR# -130 1 <br /> C-57_ WC---WAIVER.— C-57 Letter of Authori ati n o sign permit_Encroachment doc_ n <br /> � <br /> 2/ -ez-og, ���eo� -� �a r-�n,� ��e C K SZ 19 �j 2 , �Wa6 <br />