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0 • <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION IT IV <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgoY.org/ehd <br /> Well Permit Application <br /> NON.REFUNDABLE PERMIT EXPIRES 1 YEAR PROM DATE ISSUEO <br /> hmade In cmplladce with San <br /> IsoMbyadtoSanI8rto <br /> ocisorrInstalheokesc . <br /> J Application yeChapter 71163and the Standards aanEnvironmentalHaEllDepartment. <br /> Assessors <br /> ip5 <br /> Ntltr brand sty IFLz 'r25$ Parcel# ol'F ^o9U -20 <br /> 31 RKSy�/I( �croeestreet I <br /> WE"�ocanon 2 E <br /> PKOPER7rY, C City C 0 zip 91�� Phone# 'ter <br /> Owner l`r` n r 70 t O gddreae ' .y I 5^g o 0 <br /> I '- w ZI 94y��1c# fs 6`( none# 4 zS- -- <br /> C•ST contractor". -L 5;bV Address ` 5-0 I�r we 5� City t�arE P <br /> Consultant 15UIc Cntr, r�A J1.."k5 Addtess 7-Z- t=° <br /> city 5 F. a Pnena# <br /> t Range -r 5attlon .+' 3'Z <br /> GIS Coordinates:X I2, e I S 10 9.36,V 3 60`I 1L.d G 7ownehlp�� <br /> WORK T00E PEREO ED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPRODE,HYDROPUNCH,HAND-AUGER,OTHER") 9DOVER SORE.I ❑AM(ETE ea typeR <br /> U SOIL BORING# - R PRESSURE GROUT <br /> a WELL# GROUT SPECIFICATIONS <br /> x1crihsr <br /> COMMENTS: <br /> TYPE OF WELL INS YIO —C9N§=qajrIOIr=CA <br /> TI MONITORING []HOLLOW STEM DIA.OF SORENOLE" p MULTIPLE CASINGS 0 IOU EEL d PVC 0 OTHER: <br /> LTI-LEVEL WELL CASING DIA. <br /> EXTRACTION OAIR HAMMERfORIVEN CASING THICKNESS TYPE OF CASING: UST <br /> I VAPOR Il MUD ROTARY DEPTH OF GROUT SEAL—'90 ;41- TREMie TYPE TO SE USED: Q AUGERS b HOSE <br /> a AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: dyes Ii No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING d14AND AUGER GROUT SPECIFICATION <br /> APPROX.BORING DEPTH X C7 Q BOLTED TRAFFIC BOX or d STOVE PIPE <br /> a OTHER: d OTHER . f YES,/lel apad0caltons In comment section) <br /> CONDUCTOR CASING PROPOSED NU <br /> COMMENTS: IENT <br /> NOTE,: OFFSITE BORINGS OKING HOURS ICE REQUIRED FOR INSPECTIONS. <br /> ORENCROACHMENTPERMITS. <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin <br /> County Or non s, Ruled and egulti°gs,and all applicable California State Laws. <br /> µf J <br /> u Q TIIIdd <br /> Comonny j-'10 rTt <br /> Signed X-je3 9 05" <br /> Pllnt Name <br /> -C(,al.e i.... P1Gl,-er^�� Data <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: S - <br /> Dato Issued tee <br /> lee <br /> Application Accepted By Dala Flnal inspecllan By bald <br /> Grail Inspection By Date <br /> Destmetloh Inspection 8 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# PAC# <br /> PE CODES FEINPO AMOUNT REMITTED CHECKS RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> E <br /> SRO 00 41 1— <br /> C-57— WcWAIVER C-57 Letter of Authorization to sign permi$_Encroachment dart_ <br /> � <br /> EFID 25.02.001 <br /> M04 <br /> 2'd 62G'ON -inswo SAN3f AQ3NN3A WdbE:6 S002'0e'aUW <br />