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Joaquin C ,ur- h � <br /> BILE COPY <br /> s Environmental Health Department g ( �[�� SITE <br /> x 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 20MITIGATION <br /> • (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/E �11���l�J!i 1 UNIT IV <br /> Well Permit Application PEW,,11T%SE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 <br /> Assessors <br /> G" Citarcel# Z <br /> OMO ` :WELL Locatio <br /> PROPERTY lo J Z r ` (--Aw Zip�Phone#Z0 <br /> 6 —� 6 <br /> Owner l"� � 'Y` �/ �T Address � � � Ci <br /> //__ JJ; s�a <br /> C-57 Contractor 71?14 ' � Address !-6:-L H2f ,�P//- ka City,Mur� �e� ZipVV5 -5uc# / Phone# <br /> Consultant/Sub Cntr C/,t 4 �v Ch�o✓P Address S �♦- 9_I l/ City4 s� /ro.,Lic# Phone#q/ <br /> � <br /> GIS Coordinates:X3�x `fs 3. Y 1-1 " 3 Z /7 Township 2 S Range Section <br /> WORK TO BE PERFORMED; <br /> 0 NEW WELL/BORING (CPT, GEOPROBE, HY'JUROPUNCH,HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING# 2 �� 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0•Other / GROUT SPECIFICATIONS <br /> COMMENTS: VUa� L ��6tpd� /`e-4 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING )r�iOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ' �G` TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Y110— TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS b,?,' J'i` ' �G <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <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;R les and Regulations, and all applicable California State Laws. <br /> Signed x <br /> Title/Company ���„ ✓���r /h i7 '�d✓� <br /> Print Name <br /> ' Date� �1C� � ���v • �-mac <br /> ��Gn•� ;tc� <br /> DEPARTMENT USE ONLY Alto- <br /> SITE MAP IN UNIT IV FILE, ADDRESS: rr//(��' - �� NE e'—. /y' <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: O0 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2-10 -SB 32,013 -� OaoS SR# 43 q 3 <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br />