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Application Accepted By Date Issued <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br /> Area <br />ate //— Z.3 -0 Y <br /> <br />Date <br /> Final Inspection B <br />Date <br />ORIGINAL <br />WELL PERMIT APPLICATION FORM H <br />SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EMD,),, /immix/ <br />304 E. Weber, Third Floor, Stockton, CA., 952012iLL I b PIIT 14:1 018' <br />(209) 468-3449 <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 />Assessors <br />Z0 <br />/77/.16040 <br />WELL Location ,06, ni soy' Ro aj Cross Street (Apr y City Srbek ril o Zip 952 06 Parcel# / <br />epoc,0 5.40-4-AiHrur <br />PROPERTY <br />Owner Cif. Aemy AIAT: ....f-1,401-el Address CI WO 6-OEVIC TZ 4 City Sac est rtst•IroZip Vg2.6 Phone#V 6 P5 K- 3606 <br />C-57 Contractor Eri Mfre 12 Address PO SOX 6 cf 3 city Oroviite zip7516& LicOn007 Phone# 570 rt. 2230 <br />Consultant / Sub Cntr Address Vgii Ajec i,s on AvCity &Rs Lic# Phone# lie 66 3- 41 1A6 <br />GIS Coordinates: X , Y S",. Township Range Section <br />WORK TO BE PERFORMED: <br />KNEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) a DESTRUCTION (choose type below) <br />R.SOIL BORING # 3 ' iai, /3'1/ .. /3-3" DOVER-BORE. DIAMETER <br />a WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />0 MONITORING fl <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM DIA. OF BOREHOLE 2.11 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> <br />U EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE KPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />*SOIL BORING B HAND AUGER GROUT SPECIFICATIONS Me* )-- C 4 ini t el k". win.' C,f2 <br />U OTHER: 0 OTHER APPROX. BORING DEPTH Li s tq-- a BOLTED TRAFFIC BOX or I] STOVE PIPE <br />CONDUCTOR CASING PROPOSED iVo (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 />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 an tions, and all applicable California State Laws. <br />Title/Company Pv-Accr /14047er / VS ct. bei <br /> Date / 2- 7 // 7 2 00 I <br />DEPARTMENT USE ONLY <br />Z(:).E=. 5.--anc-4.1)veyf, <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, A DRESS: <br />WORK PLAN DATED: 0 2.- <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ERMIT / QUEST # INVOICE <br />”° ( z 5 ,13 87 re-- R906( 014114 <br /> <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment oc <br />