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OCT-02-200? 16:52 CAMBRIA <br /> 000299 O ►aaia .0Uw%juaas 1?07 935 6649 P.02iO3 <br /> Environmental Health Department SITE <br /> 600 East Main Street,Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Pax:(209)468-3433 Web:www.sjgov.org/chd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a Permh to cotMtruct and/or install the work described. This application is made In compliance with San <br /> Joaquin County ���oppp��� die,Cil rg.1115 3 and the$ ndards�M San Joaquin County Environmental Health Department. <br /> raw <br /> Awessom <br /> WELL Location-,Qs,�L__Awa" CrossStreet�Cgy : X►P Parcetl ZC!-19d�� <br /> PROPERTY <br /> Owner C: �Lir e�.. �4dct``res:s 2 5 9 M>�f{ �: ry ,p % ortel� 2 ca 9.-GV.Zia <br /> 047 Contractors tAisiscdc� Dii/��sAdd�n rbc fc� dr.'yt CI �7sr iCAr� Phonef `�(� �3i'-SSt'l <br /> C`onsultard/Sub Cntr.�..� �.,_�2,„rs _Address '.,e 7i alY9oe �.--PhOneIF 71�t.7S�J <br /> 56;0.0i 4 T <br /> GIs Coordinates:X -- Y Township Range Section <br /> !N_ORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT.GEOPROBE,HYDROPUNCH,HAND-1 UQER,OTHER&) ,DESTRUCTION (choose tylia bakN4 <br /> BORING#.... 8 OVERBORE. DIAMETER <br /> 0 WELLLOPRESSURE GROUT <br /> GROUT SPECIFICATIONS Pi r>t'/s.41Ij�„�„� <br /> COMMENTS: 2. V.• r( lv <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING p HOLLOW STEM DIA.OF 8 u <br /> OREHOLE.fDa $,�fAULTfPLE CASINGS p MULTI-LEVEL WELL CASING DtA:.�_, <br /> a eURACTION 11 AIR HAMMEWMiVEN CASING THICKNEJSS.L Yn TYPE OF CAS)NG: U STEEL JMVC BOTHER: <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUTSEALA&6XhdP4TREMIF TYPE TO BE USM. q AUGERS ArHOSE <br /> lJ AIR SPARGW OZONE Q MUSH POINT(OP or CPT)GROUT SEAL PUMPED: p Yee 0 No (NOTE:MAXIMI�M FREE-FALL DEPTH IS 30') <br /> 13 WIL BORING 0 HANDAUGER GROUTSPECIPICATIONS, .06'..06'. _ %tt..� <br /> d OTHER: n OTHER APPROX.BORING DEPTH &gam p BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NA (d YES,Aet=peafccations in comment section) <br /> COMMENTS r l <br /> 4++r.4[ c..;jl 41~41 3 r ��..4.rey(ls t.: je �s,sa� r�r4/ ��-�s <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEVNT OR 9NCROACHMENT PERMIT <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. 2 <br /> Signed �.�i' X44,,.o - --- —Tiddconw TrY.Lw <br /> Print Name ���, � c,r:j p� 1_0,. �Q� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 4 1 E �l, l= �'t-raz I�' e a an <br /> WORK PLAN DATED:_ <br /> Application AxeptedBy��—,t � - `u— patepsued /A -S-O Ana /4'Sq <br /> Grout Inspection ey Date _Final Inspection By pate <br /> Destnxsdon Inspection By Date <br /> i <br /> COMMENTS!CgNDtTIONs: i <br /> EFECODES <br /> NTM ONLY AID# FAC* <br /> I <br /> PPE INFO AMOUNT REMITTED CHECK N RECD BY DATE PERMIT/SERVICE REQUEST 0 INVOICE2 Go,00 (0, 00 J.004� io-s-off SRO ODs2!9S <br /> C-57 WC-WAIVER_ C-57 Letter of Authorizattan to sign pertnit_Encroachment dog I <br /> EW 29-02-001 WEB <br />