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Y war LUUb 8,h80 Advanced Geo Environmental <br /> * San Joaquin county No. 4102 P. 2 <br /> Ir <br /> Environmental Health Department is <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SITE <br /> t(209)468-3449 Fax: (209) 468-3433 Web: www.s'gov.org/ehd MITIGATION <br /> Well Permit Application UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora permit too <br /> Joaquin Joaquin County Development Title,Chapter 9-1115nstruct and/or install the work described. This application is mad,in compliance with San <br /> .3 and the Stagdards of San Joaquin County Environmental Health Department. <br /> _ _ It <br /> )p Pas�teOl#9rWELL Location 1_075_E._Q �Cross Street�kcity t"j?yWZipPROPERTY <br /> te <br /> Q.a <br /> Owner �"D � R1Addres _IM5 FAtAnck;&CityCoaZiPPh,ne# <br /> 9S')',,�'*-.1t0 <br /> C-57 ContractorAQ& Kft EA V gddress�'3! <br /> ! c City �ziP9S��SiiQr7o�P one# <br /> Consultant/Sub Cntr AV-- �OCILAJ Address Q37 S'/�eW �Qd <br /> Cit) -Lic#6��•1�7 Phone#��09�t O(O <br /> GIS Coordinates:X <br /> Y.,Township <br /> .Range Section <br /> f8'-Tr <br /> ORK TO BE PERFORMED <br /> ` NEW ELLE— <br /> (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> / OIL BORING# bNJl= <br /> WELL# DOVER-BORE. DIAMETER <br /> Q"Other a PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING U HOLLOWS rEM DIA.OF BOREHOLE <br /> D EXTRACTION I'E 0 MULTIPLE CASINGS N MULTI-LEVEL WELL CASING DIA: <br /> AA <br /> (1 AIR HAMMER/DRIVEN CASING THICKNESS_AA TYPE OF CASING; N STEEL U PVC <br /> g VAPOR p MUD ROTARY DEPTH OF GROUT SEAL_,75 fA D OTHER' <br /> I]AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Yes TREMIE TYPE TO BE USED: AUGERS a HOSE <br /> 'SOIL BORING 0 p No (NOTE: MAXIMUM FREE-FA L DEPTH IS 30') <br /> i]HAND AUGER GROUT SPECIFICATIONS _ `' 7Va /r <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH RI <br /> II BOLTED TRAFFIC BOX or a STOVE PIPE <br /> COMMENTS' V%diriri <br /> CON ING PROP t „�ED N (if YES,list specifications in comment section) <br /> walep <br /> NOTE: OFFSITE BORINGS REQ CESS AGREEMENT R ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED DOR 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 Ordi ceS, I Reg la o , and all applicable California State aws, <br /> Signed x Title/Company <br /> Print Name <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: p <br /> WORK PLAN DATED:�JO(- <br /> Application Accepted By Date Issued /G- <br /> Grout Inspection By t�wn�_ Ares <br /> a^ Date 3 0.6 Final inspection I ly r '. /—y— <br /> Destruction Inspection By Date y ��``-- Date z 1 $1 <br /> COMMENTS CONDITIONS; AQ <br /> ACCOUNTING ONLY AID# <br /> F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> -LCI vi ts9 ec z34.3`( ( ✓—/-, SR# <br /> C-57_ WCC WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment doc <br /> EHD 29.02.001 <br /> 522/04 <br />