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Aq 111N San Joaquin County ���, j <br /> 2 x Environmental Health Depart met SITE <br /> E <br /> Q. a <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 9 Z005 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www. 6 q (� 5 UNIT IV <br /> C4�rFOR�\P Well Permit Application FRr�9�T/SC V/ SCTll <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. Thi application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Hi talth Department. <br /> So ^ - Assessors <br /> WELL Location A So l iLl• W ei d L.Ac, Cross Street A I P I n P City SA t - !, Zip C l arcel# 1 L' UL / (,� <br /> PROPERTY AMZrl�u-V1 muw 1 and <br /> Owner., Ynlllw. ,/T !L,Al' -AddrJs M601 IU• (J.S.f lime- CitySlo:.k 1,j, pd/-' G:'ahone# ctly ?- S -41// <br /> 14-oo 5. J-D� 63 3 <br /> C-57 Contractor p re C I Q O n Address - Cit4 ,�L—IZipQ Uc# Phone# S%U .���T-45 Ag <br /> Consultant/Sub Cnlr 1 E(, Address i,�Lt 1014 City Ae W4M� LicA Phone# 7L 7//''X 43--.��ti. <br /> w..y 0j J.Sylc 3Uu IrJ <br /> GIS Coordinates:X—I',I -).(J S 'y �• -�_,Township aN Range_(;_ Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GE7PROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DEST UCTION (choose type below) <br /> L BORING# 9 kJ 1 S 0 OVER- ORE. DIAMETER <br /> SOIL <br /> # U PRESE URE GROUT <br /> I-Other Sttu 1 r 4J 1 y GROUTSPECIFICATIONS <br /> COMMENTS: nae/' 6vetsiq U#- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASIN : U STEEL 0 PVC 0 OTHER: <br /> U VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE PE TO BE USED: U AUGERS 0 HOSE <br /> U AIR SPARGE/OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: U Yes U No (NOTE: IMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING UHAND AUGER GROUT SPECIFICATIONS <br /> JOTHER: OTHER 0 T 0- Py5 rAPPROX.BORING DEPTH 1 — O� U BO TED TRAFFIC BOX or U STOVE PIPE <br /> ✓ pp AIn CONDUTOR CA�GPOSED f YES,list specifications in comment section) <br /> COMMENTS: O l r I <br /> 1/j o-T o 0 / <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 ii i accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws <br /> Signed x f� 6L Title/Company G <br /> Print Name 6w: L,,do/M 4, Dat( toG S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 1n, <br /> Application Accepted By \ - Date Issued A o S Area <br /> Grout Inspection By -a GIDate 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# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 13/5 3 SR# U� � SC) <br /> C-57_ WC---WAIVER— C-57 Letter of Authorizati n o sign permit_E croachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />