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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh�005'NQV 15 p13711 <br /> qL 0 Well Permit Application SAV4COUNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EkVlRo�4MENTAL ll: <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. TlhikifAi�A-A 9VaSh",hTcMomEp'1.a`nce with San <br /> Joaquin County Development Title,Chapter 19-1115 3 d the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1&4za") 4W 7 Cross Street Z01 -15�Parcet# 14 -is <br /> PROPERTY— <br /> -f Pa <br /> M di/,<—, 7*, <br /> Owner Address ziA5U2Pl­one#"D <br /> C-57 Contracto Addresi3(232-A�u ?r 4�1- cityp%d&-F4-2ig 7IV4jc#7051C'hone#`?F G+&�%?l <br /> ,5 <br /> Consultant I Sub Cntr-Ift-7 F7- Address Citygk�0&0#— Phone# <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> XEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> a SOIL BORING# a OVER-BORE. DIAMETER <br /> )f,WELL# M4�45 a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ''HOLLOW DIA.OF BOREHOLE <br /> HOLLOW STEM <br /> hl(AONITORING !'40 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: 2 <br /> a EXTRACTION !0'`AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: OSTEEL OVC DOTHIER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED: DAUGERS OHOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes a No (NOT MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS PQa-4-� I i <br /> a OTHER: a OTHER APPROX.BORING DEPTH 17 S- Fes - 0 BOLTED TRAFFIC BOX-or'd STOVE PIPE <br /> CONDYCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: �A tj .- us+ )"4 f-S 1 - - - <br /> 1-j <br /> II <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 Laws. <br /> Signed x ___Title/Company_46-2't57 <br /> PdntName aj1A;CkA 611&� Date <br /> DEPARTMENT USE ONLY <br /> iI <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I b Y V .51- <br /> WORK PLAN DATED: 1* 2 .4 c>5— <br /> Application Accepted By Date Issued 11 1/&/d S Area <br /> Grout Inspection B 'C-1 .. Date 1 <Lc, Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS:— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> -3 "-CPO SR# L4 (A C; <br /> C-57 WC_-WAIVER__ C-57 Letter of Authorization to sign permit Encroachment doc <br /> EHD 29-02-001 <br /> 6/22104 <br />