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>o u �o pan Joaquin County <br /> Environmental Health Department SITE <br /> a 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> TUU% <br /> 41.1ro %A' 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 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 5/2-1.1 1 Assessors <br /> WELL Location 05LV /UA'V''1 ARIbF Cross Street .tt 'al city S'70CK701.I Zip . . 9 . <br /> PROPERTY s� 15 ���. j <br /> Owner tr,. ,�If$Tcr DiL,° Address�5d0A/ALP'u DeltlG City Zip4'.S,n& Phon g - 7 ' <br /> C-57 Contractor V I-ti).ikiLL7114,j /A.IL Address A6,&1X`I)b�fa1City LL'D1 Zipg52�1/ LidF7ze0� Phon V -9' <br /> GGNOOr^� irrLT H /BT pp•wI_wcsT <br /> Consultant/Sub Cntr +±t�±nrir,± jtw.Y:. Addressr R,4Lf . SL=i:E 'C. City S"%aCrt-'ul Lic# Phone# ctiT�L3a'CSi$ <br /> MT � <br /> GIS Coordinates:X .2)r5 t/A• 2N LZY f° /i IG.Sc�ln 1 Township) /it% Range a �,� Section 7 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# n OVER-BORE. DIAMETER <br /> ��) 4' 00g-6 i1 ,2 JtM -ute< a PRESSURE GROUT <br /> � <br /> "Other �' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING HOLLOW STEM DIA. OF BOREHOLE_ p MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL XPVC 0 OTHER: <br /> n VAPOR p MUD ROTARY DEPTH OF GROUT SEAL—8'`3'BG S TREMIE TYPE TO BE USED: AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 3(No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 'TO <br /> `&OTHER:i �OTHER APPROX.BORING DEPTH �•^ / S z p BOLTED T FFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (H YES, list specifications in comment section) <br /> COMMENTS: Yn_'.vH Dii' �z.ff 017/1 SC1�..EEA I '/i± ('le 3$rW"6 %$B''tt� R4 13'-i'•AJ/FTr,I _ -[J <br /> > y ' I 5--7z,04-pipe Tpi�L .pe l� <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 preparesi this application and that the work will be done in accordance with San Joaquin <br /> County Ord'rfjinces, Rules and g dations, and all applicable California State Laws. / <br /> Signed x Title/Companyr/75 uam 6TH,hl tY?�k1-�41?Tlt TRA-i f ki <br /> Print Name Date S�L/fJ 7 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 'L > ' W f- <br /> WORK PLAN DATED: > -C-L d <br /> Application Accepted B/yA � �' Date Issued <br /> 1 D Area -SL 1 I <br /> Grout Inspection By. 6AAML - Date 'ttiJ1 Final Inspection By Date 8 l �- <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2k� ' $1.a.� , 0J toy D ZI,W�o� SR# <br /> C-57 ✓WC's RIVER_ C-57 Letter of Authorization to sign permitk�'Encroachment doc <br /> EHD 29-02-001 web <br /> 6/22/04 <br />