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V// LJ/ GVVI tlVl11: LJ Peen CV JVVVJYJJ JV1- Gf1U <br /> ,oPa �o *San Joaquin County <br /> • I((JVUG/ UUG <br /> 2` `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: www.sjgov.org/ehd UNIT IV <br /> 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 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 /> WELL Location 2Q® Al WA9,tJ124 4V4 Cross Street Js�IaSheMs� 9� Assessors <br /> CiIY�Zip 7/!r Parcel# <br /> PROPERT /s� QAt q/JTyN® (•e�.J •�- ALC <br /> Owner_�;)( I.oYDDi'a.'rt(7� Address �iS the a —Cit IL p28z 7S2-4+3O <br /> �o—r-- P Cit Gig 10 a Zi 77 Phone#70¢_ <br /> C-57 Contractor &ecIfcQ'1 5 'Address_/0�] ES52 X: AI/B CitCA rcl. <br /> Y �dzip9fSD8Lic#6 0F7Phone#rl0-237°44"7.5 <br /> Consultant/Sub Cnlr 111,fA✓f4 AQ a6ricw ddress_$721 P ie_i iPd.Cit SR11 UI <br /> v_�Lictt Phone#{!(� $-$3S�f <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED' <br /> W WELL if BORING (CP�TE OPROBE,HYDROPUNCH, HAND-AUGER,OTHER") �€STRUCTION (choose type below) <br /> 11 SOIL BORING# <br /> 17 WELL# 0OVER-BORE. DIAMETER <br /> p•Other &ESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF 1NEt-t INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> t]MONITORING o HOLLOW STEM DIA. OF BOREHOLE-2f 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:AIA <br /> p EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS .✓°4' TYPE OF CASING: u STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 0—//S TREMIE TYPE TO BE USED: 0 AUGERS p HOSE <br /> g AIR SPARGE/OZONE ° �MSH POINT(GP or,!�ROUT SEAL PUMPED. 9 Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> >601L BORING D HAND AUGER GROUT SPECIFICATIONS& /Nn)d ZVoe TXT7- Aila±t neon enJ`y_ <br /> g OTHER:_0 OTHER APPROX.BORING DEPTH // ° <br /> _p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED---,A/,A?- (if YES,list specifications in comment section) <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 and Regulations, and all applicable California State Laws. <br /> � r <br /> Signedx / Title/Company ��ht1w// orµiiiiii S/�C <br /> Print Name 0,j � M jk-/4G fG lsiOr Dale f)]N27 e® ' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /90 N3 S(nn yjL raiuw[n )-9-60 <br /> WORK PLAN DATED: �� <br /> Application Accepted By �� ���'"p""� I Date Issued 71;-4707 , Area -( <br /> Grout Inspection By_ rypvw't Date(/O IJ L 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 I SERVICE REQUEST# INVOICE <br /> D 135- �� ' to) v WK 727 �j SR# Odsryy <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit— Encroachment doc <br /> EIID 29-02-001 <br /> anvnn <br />