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U It car cVur nun 11: 11 rnn cv>vowa acs cnu wuuz/uuz <br /> a" San Joaquin County <br /> o •c <br /> Environmental Health Department SITE <br /> Q: <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> /FOR�`P Well Permit Application (—W-!:7-) <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 Tille,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors /1 <br /> WELLLocado f-oolr4t RVC. Cross StreetlJAEf+•.+y1dnJ city S'rbc%1o,J Zip 9521 Parcel# A11A /0- k( U� <br /> Ptoo Al o�WhShi.ryYwJ /8/0 0547e,14e> AVC <br /> PROPERTY - �' �3oeD <br /> Owner 5An1 SeA4WN CouwJ'f%/_AddressCity Seck1`hlJ Zivg5-0 Phone#_ <br /> C-57 Contractor Lm D✓r Ilw �- Address 1$'10 Mowe, Rd. CitynllRtiuM Zip"S3'5Lic#4W165Phone#925-317-111 <br /> Consultant/Sub Cntr MW04smw,L-kEI IC . Address 372,1 Pbwv City S;gc. Lica A/A Phone# 9/410 411 93R- <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EL 1 BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> IL BORING# Q OVER-BORE. DIAMETER <br /> SWELL# TW--1•'7 a PRESSURE GROUT <br /> U*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: ii <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS 5u+-40 TYPE OF CASING: Q STEEL PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL SSS TREMIE TYPE TO BE USED: n AUGERS .HOSE <br /> a AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED:%ees Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING Q HANDAUGER GROUT SPECIFICATIONS POITIAdd:El G Thr— ASQ`•f- Cae•,rn)T <br /> a OTHER:_0 OTHER APPROX,BORING DEPTH BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AJ (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 /> 1 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. <br /> Signedx I6".t • Tille/Company r1� lWff f�gMe.^Gt.�2.�-til L- <br /> Print Name ToNs/ P. IICA 66, Dale_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: (,Z <br /> Application Accepted By Are <br /> _ Date Issued a <br /> Grout Inspection By Date (� Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> d-in b 7 V-11 P I <br /> SR# Os-no <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />