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�o -,.,.dn Joaquin County <br /> a Environmental Health Department SITE <br /> W ` 304 East Weber Avenue, 3rd Floor, Stockton, <br /> J <br /> ll'\ "�.� �`� MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wvvA L,) UNIT IV <br /> Well Permit Application <br /> JUS_ 2 5 ^006 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . � I-"I _INLTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wo ri �E r� tion is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County EnPff&"n I b9prartment. <br /> ""�� 1 \\ Assessors <br /> WELL Location z22`� Jvl,nthe r lZd- Cross Street tG Sf. City _C�.-4 n Zip qS2OCo Parcel# itc3- 13L�-a7 <br /> PROPERTY + <br /> Owner M;- �JAuan _ Address 222`/ LM�NI�p� �'�. City Stoc�f,�� Zip 'N7zr Phone# �Zcf;i`(�,z- `f(,21 <br /> C-57Contractor ;k>-,ed Dr1b1.ji4 -FAV. Address 79GY 01,alam Avc City re L- Zip `55c,3Lic#!��Phone# <br /> Consultant/Sub Cntr AGS Address-R Z'7 City�S Lic#(v� 2 ] Phone# 4Zcq)t 6-L <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/BORING (CPT.GEOPROBE, HYDROPU N UGC, T Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# � � `/ Q OVERBORE. DIAMETER <br /> a-*Othe# My i I vMVV-Z 44 W -I �3l Q PRESSURE GROUT <br /> Q*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 60NITORING Q HOLLOW STEM DIA. OF BOREHOLE MULTIPLE CASINGS <br /> Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: <br /> Q STEEL >8'PV'C Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL i o TREMIE TYPE TO BE USED: W;�UGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: e-Ye's Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS�7v�a` II]E <br /> Q OTHER:_0 OTHER APPROX.BORING DEPTH 3c.' 2-9—OLTED TRAFFIC BOX or Q STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES, list specifications in comment 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 work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State <br /> Laws. <br /> Signed x Title/Company �it­ ao �og;`s{-/, 6-F_ <br /> Prin me - 1 Glia Date 7-2 5--(0 <br /> (� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2-224 M q _I' i ev Road S-F n k-6 „ A <br /> 2 <br /> WORK PLAN DATED: FG,bruary 17 onG <br /> Application Accepted By lr�1 Ci eria L. M Pn c,, Date Issued J U l v 21._ zoo/- Area I q-s9 <br /> Grout Inspection By V,c}3bri'4 1- G Final Inspection ByY NI,,, he y}Wcz, Date 9 / - <br /> Destruction Inspection By Date �- <br /> COMMENTS/CONDITIONS:Sr1 S S - _ i 0 C <br /> ACCOUNTING ONLY: �AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35o i <br /> 3503 x'14 3G 8, D sR# Q 59G <br /> C-57_ WC_,-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 4nvnn <br />