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San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov-org/chd <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Fwith Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in com a <br />Joaquin County Development Title, Chapter 9-1115.3 grid the Standards of San Joaquin County Environmental Health Department. <br />WELL Location Ia�.,..._'Cross StreeCity � - r�' `?�_ i <br />Assessors <br />t rn Zip <br />Parcel# <br />PROPERTY ) ck �e:� u.1 rr Sodtwl ASS- --t <br />Owner _ _Address_ I fllrr L . f ` ^. t {ir: City Fr z lkk, Zip 7 � 15 -Phone# 26`1/S - <br />C -57 Contractor C U✓ ( Address CS �/� t fid '` City YS"3S i' <br />Z1j_%G2� <br />Consultant /Sub Cntr Address 1933 1/, 3 i //i vz- City �h° '�' n Lic# Phone# 4 e Z - <br />GIS Coordinates: X AJC <br />1V'i , Township TZ Al Range k � L- _ Section 3 t% <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # 0 OVER -BORE. DIAMETER____ <br />.fWELL# ,tiw--t3,6 M r'r,r 0 PRESSURE GROUT <br />0 *Other <br />TT q GROUT SPECIFICATIONS <br />L <br />COMMENTS: ' ! dot <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />%MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ;___-__ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS i5 `t TYPE OF CASING: 0 STEEL R'PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL >'r i- ra u* �,TREMIE TYPE TO BE USED:-BAUGERS p HOSE <br />0 AIR SPARGE/ OZONE'PUSH POINT (GP orCj )GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nev Cl,,,* / yp-P L <br />0 OTHER:___ 0 OTHER APPROX. BORING DEPTH S. (VbLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: Pe.. Lt/eltr Yi a_q y a.r. r:, ,";/t e:_ 4.0, rZ � c 0-�- j�" P-jv td t' 4{ r � " , , _ 2" - <br />NOTE: <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. j <br />Signed x_ -1.r3 ,/�-r ~�� Title/Company <br />V �1 VYMCL <br />Print Narnes,6t::f % 1r fLA'l-t�'r ._ --- Date— <br />DEPARTM,E/NT USE ONLY L� <br />SITE MAP IN UNIT IV FILE, ADDRESS: ��� /v L �a'`/.1 <br />WORK PLAN DATED: Z - 3 - O 16, <br />Application Accepted By <br />Grout Inspection By__ <br />Destruction Inspection B <br />COMMENTS / <br />Date <br />Date Issued <br />Final Inspection By <br />Date <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PERMIT / S EST INVOICE <br />- —0,0t6 <br />SR ;--7- <br />C-57 V WC V -WAIVER_ C-57 Letter of Authorization to sign permit_ nc�men o �f <br />EHD 29-02-001 <br />6!221(J4 <br />