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o rr IJl IVur nVn 11: ep inn cv vYou JY,>J p,rL Gnv <br /> • IyJUVc/ VUC <br /> •San Joaquin County <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 SITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd MITIGATION <br /> 9LrFOR�` <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 for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location Fes/N High Scheel Cross Street Oeo AVP-. Assessors <br /> )so.V. ya-7rHl - A✓& City CA `► S Parcel#_/433_ /0��_ <br /> PROPERTY PiNRL pre. cA <br /> Owner_S}euff[W rfi' SBdeY/_Address_/93ZNerN-.6-L City S11'r4le-1wJ, Zip RS'zV5,PhonekC2.09) `333»704-r <br /> Diftvrcl waad►...I <br /> C-57 Contractor R$Z Address 220 :U Q'p57* S7,. City Zip9$`77kLic#tCZf74Phone#d &o;9•7¢2q-. <br /> Consultant/Sub CnerA46JA Aw,enuiyre Address 33 Z1jobw S„i,! *ACity r�CALic# Phone# <br /> GIs Coordinates:X y <br /> Township Range Section <br /> WORK TO BE PERFORME <br /> ANEW WELL ORIN (CP GEOPROBE, DROPUNC HAND-AUGER,OTHER') DESTRUCTION <br /> AjaOILL# 0 OVER-BORE. DIAMETER <br /> se type below) <br /> 0 'Other PRESSURE GROUT <br /> COMMENTS GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> {I MONITORING p HOLLOW STEM DIA. OF BOREHOLE 3' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NA- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER.A_ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL tr/ TREMIE TYPE TO BE USED: GERS <br /> 0 AIR SPARGE/OZONEP_USH POINT r CPT)GROUT SEAL PUMPED: Yes �U 0 HOSE <br /> SOIL BORING ( — 0 d D No NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (X-`P GROUT SPECIFICATIONS &7I 7M4r- X/ Nt�17`Gg..o,,T <br /> 0 OTHER:_U OTHER APPROX,BORING DEPTH $r--44 9_0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED NA (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 /> 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 /> tr <br /> Signed x� „P !�'�LL�n.t..✓`- Tille/Company)1461 A/w AM'SwIt,S' TW C <br /> Print Name 70 /9:�iaG LC Dalai!WO-7 <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /Z/)'S. Qar . (� � � J"l- 4a <br /> WORK PLAN DATED:C /kW(1 C!j P . - <br /> vppbcation Accepted BywDate Issued 7/a �f�D 7 <br /> Grout Inspection By 1 Area <br /> Date 4 I� - Final Inspection By Date t7 2 <br /> Destruction Inspection By p ' Date <br /> COMMENTS I CONDITIONS:CV.. XcC <br /> M <br /> AID# <br /> FAC# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> k9- 780 /dt� 7/z7 0� sR#Od5/y <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EIID 29-02-001 <br />