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I <br /> I <br /> �rN San Joaquin County G [�� <br /> ' of Environmental Health Department - SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 NiAR 2 7 200MITIGATION <br /> • (209)465-3449 Fax: (209) 468-3433 Web: www.sjgov.org/,ehd NIT IV <br /> Foes'. <br /> �'��!` JR0[u!vf'iV I -ii_ALT <br /> Well Permit Application 131:Qn.r,7I14Fr��fiV`� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor 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 /> Assessors <br /> WELL Location 1{t>LII� b 4g Q A Q 6 Cross Street R—f-M)Y1�f� City 2VOL��Y�Zip q�21< Parcel# 1 <br /> PROPERTY r <br /> Owner,-} it t_ 2ar1neYS I_P' jAddressbLI(f,S ?aeii L Ayr nufi.0l3gCity gb(.k�r1 Zip 9 2(n Phone# (ZoJ�9S3- q8 52 <br /> C-57 Contractor Adyeincedr)rc&nu+annvnle t Address A3'1 3hLtu3_Roc-d City36'kl'Dn Z0952)5 Lic# ik" Phone# (2oCt)Ll(p'1-1M� <br /> Consultant ISub CntradyanrpdCx�Fnurmmcufalitnc Address $3 7 S11GIut 1?QACI City SiDY_Lic# fokb']_2l Phone# t20R)ylt� k <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO PE EFRIFORMEDE <br /> ,*NEW WELL/BORING (QEL GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> ZSOIL BORING# E-1 I P-L a OVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT �7 <br /> o*Other GROUT SPECIFICATIONS <br /> COMMENTS: Re.�ie Yf t)Ce- ADAC k(1XL CM 1 CICAPd 14 'Fe tIA(ltiu 'U)p'li C7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING a HOLLOW STEM DIA.OF BOREHOLEL" a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: a STEEL U PVC a OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 50 TREMIE TYPE TO BE USED: B AUGERS D HOSE <br /> .Q AIR SPARGE!OZONE-KPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS Tutt I I{ F�YF IGYId ,} p.PtY1P.t1� <br /> a OTHER: n OTHER APPROX.BORING DEPT J. .50' a BOLTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ll,�0 (if YES,list specifications in comment section) <br /> COMMENTS: RQ�Q.rPl1fe-- 2QMfd'-6hhsn C04YMa AiLln kWr- 000. d0fl?d _24 PhWanA 2Q09,. <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 Ordin2tWes, lend Regulations,and all applicable California State Laws. <br /> Signed 666666 TitlelCompanyVICc I`�h(51c(eYt� �CIV[IYkiycl riPnnUi►tYlYtk�In4R(�I� <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 11,�-j 5C 15 "1 FILE COPY <br /> WORK PLAN DATED:_. ����((O el <br /> Application Accepted B Date Issued_ 3 13lTArea <br /> Grout Inspection B <br /> P Y Date O Final Inspection B <br /> — � P � Date S <br /> Y— �a 1 A <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3set �,/ SR# + <br /> 3lSoo �Rbo 3 3 3 �`Y 5 b�g I <br /> C-57 ✓W(;.—-WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 WEB <br /> 9/11/20D7 <br />