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D San Joaquin County <br /> z" Environmental Health Department <br /> K <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 SITE <br /> (209) 468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd MITIGATION <br /> Well Permit Application UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATF KOUrD <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 13-1115.3 and the Standards of San Joaquin County Environmental Health DepartmentW@LL Location � <br /> I <br /> Aaacsaa�Cass Stre '� city --Zip �f Paresl#PROP Add m"OwnQ2] CIIyhoneA <br /> jdforaCto 12C-67 CmAddress <br /> / <br /> Cit icp , Phoneil��.�� <br /> OOa51111y.,L/Sub Cn(r I, �� T •7. 'J^7�,�*-"-`-'GW� <br /> T �Llc,#a�L7PhonQ# <br /> GIS Coordinates:X Y <br /> Township�-�_Range <br /> WORK TO 29 <br /> BE PERFORAAED• SQCIIDn <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER• <br /> p SOIL BORING# ` ) q DESTRUCTION (choose type below <br /> I*Other _kA, y,—L5--ANffiE0lI � D OVE'R.URE DIAMETER ) <br /> Q'Other — 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> CPE OF WELL I LLATI TYPE CONSTRUCSION SPECIFICATIONS <br /> MONITORING I HULLOW STEM 41A.OF BOREHOLE r"� <br /> U EXTRACTION -YL._ 01 ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA - <br /> a AIR HAMMER/DRIVRN CASING THICKNESS�(1yPE OF CASING: 0 STEEL <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL r It PVC U OTHER: <br /> 0 AIR SPARGE!OZONE u PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes TREMIE TYPE TO BE UStO �AUGERS p HOSE <br /> p SOIL BORING p HAND AUGER Q It No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS f; M-f:NI4 0 ce <br /> p OTHER' 0 OTHER APPROX.BORING DEPTH <br /> I BOLTED TRAFFIC BO)- or IISTOVE PIPE <br /> CONDUCTOR CASING PROPOSED e <br /> COMMENTS: _ (if YES,list specifications In wmment section) <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 w <br /> Ork County Ord a as, Rules a ulations, and all applicable California State <br /> done . accordanco with San Joaquin <br /> _ tate Laws, <br /> Slgned x Tine/Company `V I� <br /> Print Name Z p j-C 6 <br /> v <br /> DEPART ENT USE ONLY Date <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 121S. GLI lin( <br /> WORK PLAN DATED: A y <br /> + <br /> Application Accepted B ' <br /> Grout Inspection By Date Issued_ 1 (, Area I S <br /> SLA Oafi° Flnel Inapectfon Dy Uete Z Q <br /> Destruction Inspection By � Da e <br /> COMMENTS I CONDITIONS: .,} <br /> jr�d Wei <br /> �AUJ -22 �n1AA 7R <br /> ACCOUNTING ONLY: AID0 <br /> FAC# <br /> PF CODES FCL INFO AMOUNT RLMITTED CHECK# <br /> R6:cO SY DATE PERMIT/SERVICE REgUEST# INVOICE <br /> 0 <br /> 3503 Cl 384. gS SR# L <br /> C-57 WC C-57 Letter of Authorization to sin ermit <br /> EHD29-02-001 9 p ,Encroachment doc„ <br /> cr22/a4 <br />