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u rr ear avur <br /> Oan Joaquin County <br /> `? Environmental Health Department SITE <br /> y. 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> P ' (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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location /90 Al. Ali Cross Street Assessors <br /> Y 57ve :low7Zipg521SS <br /> Parcel# 15902010 <br /> PROPERTY <br /> Owner MR. _ pe Address--Z _r City SW6errw.-1OZip In/L Phone# 2& -O -2L{Z <br /> C-57 Contractor RQ Dr.fli.w Address 220 V.Basr ST. City Wadlwvd Ziperne Lic#�Phone#S30-bb$-24aF <br /> lLorw�'ir✓ R.A. <br /> Consultant/Sub Cnlr MWI'I,Atisri u.S Address 3321 City.Swe'hJ. Licit Phone# <br /> GIs Coordinates:X(.34495 �I'$r,Y LI75*I1T 4S1 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 11NEW WELL I BORING (_CPT EOPROB ,HYDROPUNCH, HAND-AUGER,OTHER") AMESTRUCTION (choose type below) <br /> SOIL BORING# .J �OVER-BORE. DIAMETER <br /> 0 WELL# �RESSURE GROUT <br /> O 'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSS TION TYPE CONSTRUCTION SPECIFICATIONS <br /> I]MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEZf� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: A!A__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS A1.4 JYPE OF CASING: 0 STEEL 0 PVC T.ER: A,,4 <br /> I7 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL B^ar TREMIE TYPE TO BE USED: 0 HOSE <br /> p AIR SPARGE/OZONE 'PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS fb,-HAhJdL nj! != !>:' j4AVf_ fg.yJt' <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 1?f p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A"* (if YES,lis(specifications in comment section) <br /> COMMENTS: SOIL {t�rim<1 6111 lot u.3id '64! 9!A_V!&5 .a.rd 14.e..l ,►b,.,,,Js,.t P'" SSC Sparct <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 /> Signedx --1Z..^,i � Tiue/Company_ pjLt MWN Re..r�u.S� .T,yc <br /> Print Name �Owt./ 141K4GICA+ Date_ 67�Z3'/0 L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /SU ti, a* kc�a CZu( S l ac p 2`f_1. <br /> WORK PLAN DATED: <br /> Application Accepted By Dale Issued 715411 _Area �7 <br /> Grout Inspection By Date /A Final Inspection By. Date <br /> Destruction Inspection By Date/ <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY -DATE PERMIT/SERVICE REQUEST# INVOICE <br /> i o) 8ti 00 g� Imo- Thy e, sR# leas <br /> 3 ,37 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> El ID 29-02-001 <br />