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f ` <br /> 9— 1-06; 12:24PM; ,2099836960 # 2/ <br /> i <br /> 1 <br /> San Joaquin County <br /> z Gx Environmental Health Department SITE <br /> y. 304 East Weber Avenue, 3rd Floor, Stockton CA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sj'gov.org/ehd UNIT IV <br /> Well Permit Application '200b AUG I I AM-410i'; <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE� J0A0WIN 1.10UNTY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described.E-NiV f FQ- e 1 N compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County EnvironrUEt�L l e$ r`erg <br /> j `` Assessors <br /> WELL Location 05'0 �acysE At-7 Cross Street y- City L.C��iz.'za _Zip Parcel# r%�p,/4C-G�' <br /> PROPERTY <br /> Owner iQi2 ��,� /,�vss��itj Address 2y So E jt yj�CityZATii/�Pc.�P Zip Phone# �Yv -SJSX/ <br /> /o <br /> C-57 Contractor rflsorl�.e CorAddress/2yGy Me Cee4n .00. city_S� !gVAS._ip 90(oyLic#. iphone#lSrzJ906-19 0 <br /> CA <br /> Consultant/Sub Cntr C�i2Q Address 2 aZ V,21 bervrn Lky City�i,�/W Lic# Phone# J <br /> GIS Coordinates: X Y Township Ttl sRange 4• Section <br /> WORK TO BE PERFORMED: <br /> n NEW WELL/BORING (CPT,GEOPRODE, I IYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> J]SOIL BORING# OVER-BORE- DIAMETER <br /> ,'WELL# RW 2S O® PW2i '/SJR �r12S-Z 60 a PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> j TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ?['MONITORING Q HOLLOW STEM DIA.OF BOREHOLE_ U MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: <br /> [I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5eA eeO TYPE OF CASING: d STEEL $PVC 0 OTHER: <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL Yb' /'S/e / e TREMIE TYPE TO BE USED: p AUGERS XFiOSE <br /> p AIR SPARGE/OZONE 1]PUSH POINT(GP or CP[)GROUT SEAL PUMPED:A Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER , — GROUT SPECIFICATIONS lVeal <br /> p OTHER: O OTHER 3Osa/C APPROX.BORING DEPTHAPOZ/T <br /> BOLTED TRAFFIC BOX or XSTOVE PIPE <br /> I CONDUCTOR CASING PROPOSED—,f—L_ (if YES,list specifications in comment section) <br /> COMMENTS:_- 12- <br /> NOTE: <br /> ZNOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> i <br /> iI 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 Californian State Laws. <br /> Signed x---lJ .- Title/Company <br /> Print Name U Pvf J Date O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE, ADDRESS: Ste-�p 4 IL T71'I <br /> WORK PLAN DATED: AL -� `1, 2- <br /> Application <br /> Application Accepted By Date Issued)/L f� Areae_ <br /> Grout Inspection By Date 8 23 OL Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: CU L/Zr`JQ CL5 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> T T— <br /> C-57� WC;WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 — — --- -- <br /> 6/22/n4 <br />