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mai vol cwo U! :44 rr\A aibo/yz9uu URS-SACRAMENTO-GO 0002/004 <br /> 0 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 Fast Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> 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 compliancewith San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> /�,, �K"�v'f Assessors . <br /> WELL Location .1.. ?b(� UrLs�fi� Awl Cross Street C�arr�s'h.Atj Ci Zip�7� Parcel# '- 07'90 2- <br /> PROPERTY <br /> PROPERTY ACAS ��XJt n2 goo KIM. 'Z- <br /> Owner! C�vFrti�l,, ,,a- Address ��rQv�Gyv�lSv,,p l �City-TY1,ac_�Zipj59 37 Phone# 0 <br /> C-67 Contractor.4 6� J ✓� Address 2R//pK*F 1W.. City/ ,4,r-W?,A I?_-zip94S33Lic#6F ��3��5 M <br /> Consultant/Sub Cntr t � ' <br /> Address?$?C7 C t�itYi14L, Lic# Phone#S/& 4-117 24O <br /> GIS Coordinates:X� ,Cr_F�S�Y <br /> �1� ,Township Range.____-======— Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> 'JPSOIL BORING# 7' Ar U� q Gpr a OVER-BORE. DIAMETER <br /> Il WELL# 7 0 PRESSURE GROUT 1 <br /> a*Other GROUT SPECIFICATIONS S <br /> COMMENTS: S'K+� f�F� �yP ✓ L�% ^ J� /`✓,a ' S <br /> �J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL o PVC a OTHER: <br /> a VAPOR u MUD ROTARY LIP OF GROUT SEAL__ TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE)OZONE ACBUSH POINT(GP oy[Py GROUT SEAL PUMPED- 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> o SOIL BORING o HAND AUGER �L// GROUT SPECIFICATIONS S <br /> Q OTHER a OTHER APPROX_BORING DEPTH 'p16n, BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ✓j�� .ZS c T-,r-i.FF?/vV-'-- =n 'A ?-'7 <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 xell <br /> Title/Company q � <br /> Print Name / Vii? �n�r./ Date / — Z 2 r9'!;'t' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: G� <br /> Application Accepted Py Date Issued l�G/D Area 9�7 <br /> Grout Inspection By �'N*Y.f Date Firal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: CV✓L © �Jo✓Q S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY I DATE PERMIT/SERVICE REQUEST* INVOICE <br /> i ` 11-8bs 4� -- 9 t o S oo�fg <br /> C-57 WC--WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc� <br /> EHD 29-02-001 <br /> 6/22104 <br />