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San Joaquin County o <br /> Environmental Health Departr�� n SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 V MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgA ** UNIT IV <br /> ., V <br /> 200 <br /> - Well Permit ApplicationE � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE15 l ��FACTF/ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This alicatlon 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 /> Assessors <br /> WELL Location 3 W E. ht.:.. 3t-lee Cross Street 2,, 4p 1531,1 Pareeil/ Z G I-I Yo-0'7 <br /> PROPE <br /> Owner •ani +F.r�1e_ Addresss,,��,,3.55*Y6--ova,,ILc:,., City lriteen�¢��Yt�Phone* �A <br /> C-W Contractor TrsetlT ee ,, /i/���4d3eC3ss 319.6 Layc...a p�:..� City °�dL p j is 87?�1jPhone 9l1�5.1':SSLS/ <br /> Consultant/Sub <br /> CntrL.,sr �-/G..e/sr°/�3dsress{�Yr/SR.LC.t�`� , �urCily,�Qe9.4 <br /> Ur Phone#�o7r-9�3�L9 <br /> J"Jft <br /> GIS Coordinatex X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT.GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER) DESTRUCTION (choose type below) <br /> Q SOIL BORING rY D OVER-BORE. DIAMETER <br /> Q WELL* MPRESSURE GROUT r <br /> D*Other GROUT SPECIFICATIONS `* cO-e..+. <br /> C MENT �orri ML'--1 ---Z -3 - • <br /> TYPE OF WELL INATALLATION TYPE CONSTRUCTION SPECIFICATIONS N N <br /> 1`BMONRORING p HOLLOW STEM DIA OF BOREHOLE_ ft'D MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA Z� <br /> Q EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS.54(Z2 TYPE OF CASING: Q STEEL J(PVC Q OTHER: <br /> Q VAPOR D MUD ROTARY DEPTH OF GROUT SEALt R-Yt ATREMiE TYPE TO BE USED: Q AUGERS ,S'HOSE <br /> D AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: JR'es ,D No (NOTE:MAXIMU FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS,P�756�.s :1=1 Geo%#A _- <br /> Q OTHER: a OTHER APPROX.BORING DEPTH _ D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> 9 CONDUCTOR CASING PROPOSID A!A (If YES,list specifications in comment section) <br /> COMMENTS: <br /> eu+rt 4 $ wall c-:U 6 �//•7ss swsJ &j i.- He. cR„s;-2 <br /> NOTE: OFFSITE BORINGS RE�UIRE A&M AGREEMENT ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will.be,done in accordance with San Joaquin <br /> County inances/, I a e ulations,and all applicable California State Laws. <br /> Signed x Z!1 C/" Tkle/Company Q. <br /> Print Name r, Data C l <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: E S+Iriza+ rR1621M <br /> WORK PLAN DATED: s Pir Z <br /> Application Accepted By Date Issued /0-Sr-D rI "a� <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: -- <br /> i <br /> [ACCOUNTING ONLY• AID# FACE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST S INVOICE <br /> 3SD2 Go.00 �0. D� X0045 �%`�L /o-s'-a SR# 0052/ 94- i <br /> C-57 WC---WAIVER- C-57 Letter of Authorization to sign permit Encroachment doc_. <br /> HHD 29-02-001wcb i <br /> 6=D4 000298 I <br />