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l <br /> A <br /> ,o q '"•. San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> c•.. P^' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> 4</k0 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. 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 Department. <br /> / ' 1 '"_�\�� cry1 1�1 Assessors —1 <br /> WELL Location fj� WexAk V oon 16 Cross Street ill,nculn Sh City 3.68-68zip%'2,03 Parcel# �3•� O-O,� <br /> PROPERTY y=�,�,'-- Gy <br /> Owne � �.w:-�w�..,,� Ac..... +L Address �+u.�u .�•�. city Axk Zip /r IO? Phone# <br /> C-57 Contractor_ cc.�r UL 11`✓ . Address Jcc 2c+a <br /> G.s o 363a Or+u �, ti\a CityLYrO�_µ1 Zip 'tL Lic#� le Phone#�w-G38-1165 <br /> Consultant/Sub CntrS&,C*Xn�tit+ RaAl Address3ol�-IG+�yarc fj . CityLic# Phone#9/6-f'61-0wo <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> DWELL#_ a PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: 1P ci-r„nt✓1¢r wall$ i OK ex*U K• "I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING &HOLLOW STEM DIA.OF BOREHOLEN" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> )9 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS &I, +-i l7 TYPE OF CASING: 0 STEEL ®PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: IrAUGERS' OS <br /> HE <br /> O AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Dyes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH 30 Fwil 0 BOLTED TRAFFIC BOX or )a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: pzc+VA'( s tiallU+.%Sk.�.., I-�+(� 36,,; � / '14 I. l %kwi sa k✓ M r�A.. -! 6-6- ker <br /> KSI <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/Companyy FC/C,T,h <br /> Print Name OAT (.,, I t�M, Date � 'r '��(! <br /> Gj�ZI/0/ SGrn <br /> DEPAJZTMEEONLY <br /> SITE MAP IN UNIT IV FILE, ADD[REiSS' �,-�S <br /> WORK PLAN DATED: <br /> Application Accepted X4 Date Issued '"ri - / GWt ,gree <br /> Grout Inspection Byr Da Z / final Inspection By Date <br /> Destruction Inspecti n B tDgte <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 /> c D l 99 -00 C4�S4(- �/ 3 p SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho Izotio o sign permit_Encroachment doc_ <br /> EHD 29-02-1X11 1/ l +0 /� e ^S q <br /> 682/04 1/ <br />