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C�atit . <br /> ,..m ari Joaquin''County <br /> Environi <br /> .eent,►.i Health Department SITE <br /> 600 E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> ,� v' (209) 468-3449 �x: l,2(,9 468-3433 Web: www.sjgov.org/ehd <br /> \ f i', �I <br /> � � :; U"N IT 1V <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 and/or install the work described ?7h`ii7application.is•made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 of San Joaquin County EnvironmentahHealth_'Depa friterit '1! <br /> WELL Locatio, _ • Q /`�` �+ Assessors r <br /> G Cross Street'r 1-A City, 7�Uv "I Zips u" Parcel# 7���6-25 <br /> PROPER L <br /> Owner <br /> Address 9 �Itj .�� <br /> rr�� <br /> t dip iL' i�hone* <br /> G57 Caniracto .S - '1c' = ^ CE 7 <br /> address—' ✓�� 171 ` �! t <br /> ��`City ?t ® �Q <br /> Zip"l �Lic# ��Phone# <br /> Consultant/Sub Cntriqr"1C /} ` <br /> Address'_�/"7 C�17ur KGS City-� Y Lic# ' , <br /> Phone <br /> GIS Coordinates:X Y � <br /> Township _ Range Section <br /> WORK TO BE PERFORMED.• <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ZdESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> 0 WELL# g'{SVER BORE. DIAMETER dr A <br /> 0*Other �rPRESSURE GROUT i <br /> GROUT SPECIFICATIONS ' <br /> COMMENTS: Ff� l�� `[�d3 " n'llc1�-5 'TDSS" $`,' Qc� I .Gay TO ra�'Pr�sctre <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 4 <br /> MONITORING A'I�OLLOW STEM DIA.OF BOREHOLE f!�` Ib MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: G a <br /> EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS /fir TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: .0 AUGERS 0 HOSE 1 <br /> ,ffAIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,D'Yes Q No.(NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS__ ;57]« 7 <br /> 0 OTHER: 0 OTHER SAP 30g0Xo,SWIING DEPTH `.. L Ti. []BOLTED TRAFFIC BOX or O STOVE PIPE <br /> V�� rT� gk vBUGTC�R ASI P (if YES,list specifications in comment section) <br /> .36/ `1 brvl r4� V i41-d- '41'-M t durrd�i,X <br /> coMMENrs: t Off'- . ^ v 4 1`or� a <br /> V")-3 TD SO' tortp oe VW Ta 441 I0rILWUAe(a-inaa4.,,e� VU)STdtior tell Al-uAA r�,f <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 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 Regu ations, and all applicable California State Laws. <br /> Signed x_ it 7 I �a A <br /> 1 Title/Company. `?� l rJ - <br /> Print Namer vv I L&I.111 `— Iv G Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /D �nara <br /> WORK PLAN A?�: It1,P–d <br /> r I <br /> Application Accepted By e Date Issued -! Y 1� Area <br /> Grout inspection By Date�. Final.Inspection By Date I <br /> Destruction Inspection By Date i <br /> COMMENTS/CONDITIONS: F- IPI--A53 0` T( arc - t'II e'>:�4yTD '91I d&C�lr,11 O ZI s'T <br /> l . <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> LO U <br /> AAC SR# <br /> C-57 WCC WAIVER— C-57 Letter of Authorization to sign permit— Encroachment doc <br /> F-HX2104-02-001web �,�?Q{l<5 <br /> r t t►�. `t<�C� d 3 r Swla,-,—i"L Lu e[I <br /> �A C� ,� a CAStvt� <br />