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c 'N. San Joaquin County <br /> Environmental Health Department SITE <br /> ^; { 304 East Weber AVCnllc, 3rd Floor, Stockton, CA 9202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wMSjowjof�ehc�,'O• 37 UNIT IV <br /> Well Permit Application . <br /> ' UNTY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM o,ATE14 EN'DTA !_ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wok des6AW,'l;­IEksT* igtlon is made in compliance with San <br /> Joaquin County Developmbnt Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> q2 4 Syifef S1' (Y2°Z� o $� S7�CICTa1 �?�2a� Assessors 6 -0 <br /> WELL Location ��c,0 ross Street � City Zip Parcel# IIS 'Z 3 <br /> PROPERTY u 24 l � e,� ,e rl u <br /> Owner L'A b ra- 1 Address-1 '1 d1!TT J7(.L City TD�Lj1f! lJ Zip q�q�Phone#�gZ,O�q" t le4'p�3,�y,�3 <br /> I tAddress��762, F°(&i )7 , 0-7Cit bt41wdr Zi !W Lic#7d M7 Phone#I ftV? 3 <br /> C-57 Contractor V I TD fit c- ( -� ?!t ,(� y (� p <br /> Consultant/Sub Cntr hahe`/ C/cdt�LMYII Pa��q dress7�z��/r' �/ ..—City-..--­- <br /> GIs <br /> ityu r`-­- Llc# Phone#Z/(O �� <br /> —12—,kJ <br /> GIS Coordinates:X 'y ,Township Range 1 Section <br /> WORK TO BE PERFORMED: 2 \2jt)r t Nl S �p/lS �� Z3 CJIO <br /> EW WELL/ BORING (CPT,GEOPROp HYDROPUNCH.HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# 2- Eco pro []OVER-BORE. DIAMETER <br /> []WELL# �— []PRESSURE GROUT <br /> []*Other_ GROUT SPECIFICATIONS"?Wf CP fhC-ice' <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING []HOLLOW STEM DIA.OF BOREHOLE-7 []MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> []EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL Q PVC 0 OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL i" TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> []AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ASOIL BORING aHAND AUGER GROUT SPECIFICATIONS h Pa.-t C e 4,1 Gh -f- 6ak <br /> (]OTHER: []OTHER APPROX.BORING DEPTH IS 2 a 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <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 have prre this application and that the work will be done in accordance with San Joaquin <br /> County Ordinarw, egulations, and all applicable California State Laws. <br /> Signed x Title/Company l�'/ Ile <br /> Print Name (/ V Date D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 9 2-" N, 5Kt{ 54 <br /> WORK PLAN DATED: I <br /> Application Accepted By ( 'a v C - Date Issued I O r/ Q to S Area '42-ir <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> Lj- 1619aS SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> El ID 29-02-001 <br /> ei'-2/04 <br />