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San Joaquin County <br /> voall <br /> 0 <br /> FILE COPY <br /> Environmental Health Department SITE <br /> 4 <br /> y- 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> ' (209}468-3449 Fax: (209)468-3433 Web:w .sjgov.org/ehd <br /> •' UNIT IV <br /> °<< 0R 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 tha work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1116.3 and the Standards of San Joaquin County Environmental Health Department. <br /> IF 2333 N.,GaL.I�. !t 01� Ci ?06- 70A✓ p Assessors <br /> WELL Location �T Crass Street /` -city � Zi �5Parcel# •� <br /> PROPERTY/ L •�, 8N <br /> Owner .!� VG ` J ddress �y City Zip Phone# <br /> C-67Con ltractor xe,44 �7U Address -l.0/y� Z� Ci � 'TIS Zip 3Lic#�O�O4"7Phone# ��S 3�3 529 60 <br /> i el"g2 S7o cy vZrDG Aµ�oPep <br /> Consultant Sub Cntr�HILL AWZL(L Address w City Lac# 7747 Phone# ��6 TZ 9 ��0 y <br /> GIS Coordinates:X Y Township Range Section <br /> IM <br /> pRK TO BE PERFORMED: <br /> NEW WELL 1 BORING (C GEOPROBE,HYDROPUNCH,HAND-AUGER,O HER*) 4DESTRUCTION (choose type below) <br /> �n]SOIL BORING# OVER-BORE. DIAMETER <br /> WELL# A PRESSURE GROUT <br /> 'Other C ? GROUT SPECIFICATIONS �7O 14,0 pE� <br /> COMMENTS: I : Z `?V 1,6 <br /> TYPE OF.WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [] <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Z []MULTIPLE CASINGS n]MULTI-LEVEL WELL CASING DIA: <br /> n]EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: ]]STEEL n]PVC []OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEALw�� ;O-T,14TREMIE TYPE TO BE USED: n]AUGERS []HOSE <br /> U AIR SR4ARGE1 OZONE USH POINT(GP or GP GROUT SEAL PUMPED:>dYe a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AF <br /> �SO[l.BORING I]HAND AUGER GROUT SPECIFICATIONS.srD l4 }( O P 9 y/b S�u� cam.-,6- ' <br /> U OTHER: U OTHER APPROX.BORING DEPTH ��� 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPO ED (if YES,list specifications in comment section) <br /> COMME TS: of ja f�L���/�j2s CP-T�` Z /V!/L?H <br /> NATE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUI ED FOR INSPECTIONS. <br /> �C <br /> 1 hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin <br /> County Ordinances,,Pules a Regulations,and all applicable Cali orrila State Laws. <br /> Signed LLu �� _ TitlelComp iny <br /> Print Nalene /`G� 1/ L 1A- Dale <br /> I� DEPARTMENT US ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2-315 N - C&QLf D <br /> WORK PLAN DATED:. -dS <br /> ApptiGM n Accepted By Date Issued 'l T '�S Area <br /> Grout Inspection By Date Final I ispection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOIUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 368 i 0 3 [aZ-n5 SR# <br /> C-57 1C WC,/-WAIVER_ C-57 Letter of Authorization to sign permitEncroachment doc_ <br /> EHD 29 02.001 1 <br /> 6122104E <br /> 0 <br /> I' <br /> I <br />