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FILE COPY <br /> San Joaquin County <br /> D1Q Environmental Health Department SITE <br /> MEALTH 344 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> VICES(209)468-3449 Fax:(209)468-3433 Web: www.sjgov.org/ehd 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 permit to construct+andlar,instail the work described. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards,-6f San Joaquin County Environmental Health Department. <br /> Assessors <br /> IIYI~LL LocationCross Street ��*�►z Ciiy ,�kN^r_ Zip Parcel# �`t ti 'Z(60 02 <br /> PROPERTY <br /> Owner 6L nry_ (-G+'rm-s LnC Address kla&6%�_ f __St City c>`�bSe Zip (6PPhone# F(U6 2cl2 �t(;(o <br /> 1.44-e OAD ��3�`(c ? <br /> C-57 Contractor p4D C Address_I_�icct_lnQekwr f re City Qticl,vr.,�ci Zip��Uc# Phone# 99D a_ t &155 <br /> Consultant/SubCnV (,00'5 [prv- <br /> k Addre's}sP6e63y- City Sas t, ,Lic# 1/31fo5 Phone# 642 4ggf <br /> GIS Coordinates:X Z Y F.. Z T[ Township_ ._ _ _ Range Section h <br /> WORK L BE PERFORMED: <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> (]SOIL BORING# i]OVERBORE. DIAMETER � <br /> Q WELL# '_2-PRESSURE GROUT <br /> 0*Other 6ROUT SPECIFICATIONS iA <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS 0 MULTI-LEVEL_ WELL CASING DIA:_ <br /> /U EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASENG: p STEEL p PVC a OTHER: rs <br /> 0 VAPOR 0 MUD ROTARY . ' DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS• a HOSE <br /> ]]AIR SPARGE/OZONE II PUSH POINT(GP or CPT)GROUT SEAL PUMPED: (]YesNo MAXIMUM F EE-FALL DEPTH IS 301) <br /> n SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS .04 .� <br /> ]]OTHER: II OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC 80x or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED -, (if YES,list specitiicatlo <br /> COMMENTS: LLS"( ' z MW-3 All 2" 2�i r re-' , c yrt,J alae <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cerci hat l hav pre ared this application and that the work will be done in accordance with Sara Joaquin <br /> County Ordi es, a eglilations,and all applicable California State Laws, n <br /> Signed Tltle/Company / / -- "!ac <br /> Print Name Date ZZNZ/O ` <br /> DEPARTMENTUSE ONLY. �9..s! <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a. _ <br /> WORK PLAN DATED: 13 Zo/o <br /> Application Accepted By Date Issued;- t tita7 QO r <br /> Grout Inspection By Date Inal Inspection By <br /> Destruction Inspection By Date /O <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CH tE'C/K# RECD BY DAT£ PERMIT I SERVICE REQUEST# INVOICE <br /> C-57 WCC WAIVER__ C-57 Letter of.Authorization to sign permit_ Encroachment doc i✓ <br /> EHD 29-02-001 <br /> 6r12104 ;. <br /> a <br />