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{an Joaquin County av <br /> -��'- •••c <br /> ' °G ental Health SITE <br /> Environm <br /> - { ucL 9D47 MITIGATION <br /> y . , 600 E. Main Street,,Stockton, CA 95202-3029 <br /> �. (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.orglehd. 'UNIT I <br /> c, �� ENVIRJNNIENT KEALTh <br /> R�IA�7¢� _ Well Permit Application PERMIT/3E.FMCI <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 DepartmentAssessors <br /> WELL Location IM99 JN,slI <br /> Cross Street,RUazSOC'K�zCI City l_arl� Zip�S i1 —Parcel# a�S 0 CS <br /> PROPERTY Address l ;RRq. >AIP- gW, !� City t (� + zip gSAa Phone# <br /> Owner �` �— <br /> C•57 Contractor AddressL5-1 ghCtRL �zd city Y Y1 ZipRS�IS Lic#lth(i_?2,Phone# DD� 1{ta 1 16W <br /> 4 <br /> gtMj4ec ` Lic# Phone# - <br /> r - <br /> Consultant 1 Sub Cntr lulti�r�merl RmF�,�l;rmmrrri>�_Address $'��t 3YtQU3 RSI _Cit Y - <br /> GIS Coordinates:X3,.I ,y -42-1 N-5 Township Range <br /> Section <br /> WORK TO BE PERFORMED: `r' <br /> `gCNEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*)-, p DESTRUCTION <br /> S" (choose type below) <br /> SOIL BORING#'R5-- B9 Cttr.�`�' 3V 1-SVS: U OVER-BORE. DIAMETER <br /> — <br /> a WELL a PRESSURE GROUT, <br /> p"Other r a * GROUT <br /> • SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE V, S 0 MULTIPLE CASINGS p MULTI LEVEL WELL CASING DIA:-— <br /> n EXTRACTION 0"AIR HAMMER/DRIVEN, CASING THICKNESS + TYPE OF-CASING: 0 STEEL, a PVC a OTHER: <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL4+o"1� TREMIE TYPE TO BE'USED: U AUGERS q HOSE. <br /> s []AIR SPlA!�RGE!OZONE !PUSH POINT(GP or CPT) NS <br /> SEAL PUMPED: n Yes �No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BbRING Q HAND AUGER GROUT SPECIFICA710NS 1 4 ""t i1 r+ Yl YL'� <br /> OTHER: []OTHER APPROX.BORING DEPTH U .:+u l0` b Q BOLTED TRAFFIC BOX or n STOVE PIPE <br /> lu <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 /> hereby certify that I have prepared this application-and that the work will be done in accordance with San Joaquin <br /> ' County Ordinancn, uleLsand 4Reul ons, and all applicable California State Laws. <br /> Signed) <br /> TitlelCompany 1]1C 2 �51dC"r iE f y1r11tftYlf(ri f�P_CkEnVtif1Y111IP�F 11-1 c.. <br /> Print Name Date q r aao� 4 <br /> DEPARTMENT USE ONLY ,. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> l .. 4 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued" / �Z/ (' Area <br /> Grout Inspection By Da Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> l ACCOUNTING ONLY: AID# FAC#i' x <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# �- RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> �q SGS 17— Iq a sR# D53z� <br /> C-57— WC_-WAIVi=R� C-57 Letter of Authorization to sign permit! :Encroachment do <br /> cN - <br /> EHD 29-02.001 web <br /> 6122104 <br />