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San Joaquin Count <br /> rjj'E <br /> Copyy <br /> _•'' - °2 Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: .sjgov.org/ehd UNIT IV <br /> i <br /> rQ65, Well Permit Applicata n ' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED off <br /> Application is hereby made to San JoaquinCounty fora permit to construct and/or install th work described. This application is made in compliance with San <br /> Coun <br /> Joaquin County Development Title,Chapter 9-1116.3 and the Standards of San Joaquin County Environmental Health Department. <br /> IIA, G � € Assessors <br /> City�7KTO 1Zip Parcel# <br /> WELL Location � 1 S-t Cross Street Z5 ! <br /> IM I <br /> PROP NE 57. R�LTN �t�Address23Z0 n6`C, L16,,St# pity S oG,rrTa.� Zip �5 Phone# �� 46 ��O <br /> 11 iu& <br /> C-57Cantractor 44&44 llVS !7U Address ��� IE Z.p4W3 Lic# �O Phone#'1Z5 313 9500 <br /> ; <br /> b'�/�l2 S7o arOyE <br /> Consultant ub Cntr�wlr,t IV4�' Address / ""° CitA� L--" Lac#5- 70'7 Phone# '7/& 72'7 S7�y <br /> I <br /> GIS Coordinates:X Y Township Range Section <br /> I <br /> WORK TO BE PERFORMED: <br /> NEW ' ELL/BORING (CPT.G.EOPROBE,HYDROPUNCH,HAND-AUGER,Q HER`} DESTRUCTION (choose type below) <br /> a SOIL BORING# []OVER-SORE. DIAMETER <br /> LL# PRESSURE GROUT nn <br /> �pYVE`Other GPT '� f _- GROUT SPECIFICATIONS �7a/019'd C�pC Z <br /> o.� <br /> CQMMENTS: • y��6 SAGK. <br /> i <br /> IM <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE;Z" a MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br /> ©EXTRACTION (]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ©STEEL Q PVC []OTHER: <br /> []VAPOR p MUD ROTARY DEPTH OF GROUT SEAL FUIL 45 l TREMIE TYPE TO BE USED: []AUGERS HOSE <br /> {]AIR SPARGE/OZONE PUSH POINT(GP or[ P GROUT SEAL PUMPED: Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 34') <br /> SOIL.BORING /a HAND AUGER GROUT SPECIFICATIONS S o �0 y � �'� ���� �� "A- <br /> Z <br /> / OTHE a OTHER APPROX.BORING DEPTH_5V'0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: V0 ULA CL E—AA/c12 5 GPT S15 9Yzn i'l'l f-"erPiG.4 e- i An a4'iw� <br /> S t?E5 <br /> NONE: OFFSITE BORINGS REQUIRE ACCESS AGR EMENT OR ENCROACHMENT PERMITS. <br /> 1 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTION& <br /> hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin <br /> County ordinances, Ryles andel Regulations,and all applicable California State Laws. <br /> Signed x11 ` J -- _ Title/Company Ul e' 1�✓��T12 <br /> IM // L G Date <br /> Print Name <br /> II DEPARTMENT USE. ONLY <br /> SITE MAP IN UNIT IV FILE,ADDR S: 2315 /V <br /> WORK PLAN DATED: <br /> 11 io-i3�o 5 410 <br /> Application Accepted By D to Issued Area <br /> Grout inspection Sy Date Final Inspection 8 ate <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED ' CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C_57 WCC WAIVER C-57 Letter of Authorization to sign permit✓Eneropeln'm <br /> EHD 29'h02-001 p <br /> 6/22/041 <br /> f <br />