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)o ut • San Joaquin County L0 <br /> _ <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: 20rvj 4g/f" (, 48 UNIT IV <br /> Well Permit A licat' <br /> PP �(?,��pE r;:,a,;;:a Cc.u �r <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR Ff l d (A L <br /> lthworkdescrr ARTMENT <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-r11-15I.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 �^( ��✓��[ r^ Co 5 - Ci Assessors <br /> WELL Location w r'ross Street �n ty 'p,� Zip C Parcel#_Lit. O��,-6 <br /> J <br /> PROPERT" <br /> owner Rdse V e 24 <br /> evS rYUSLAddress IOQqO /)c1vf r, Rb—City 5 {oh -Zip PhoneirZO Y��330r <br /> C-57 Contractor 1,4-)o") .-.a) Address SSS Q.,ret. Poo . City Ale � s Zip NSA( Lic#jCA22Phone# .i'lr-} 3 k 43cyc <br /> Consultant/Sub Cntr IJ a S Address Zy}c (ra2wa, 105 City [fd Lic# Phone# 'l l(4 (c� '2 7 C <br /> �3av <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: . <br /> j(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) tESTRUCTION (choose type below) <br /> 0 SOIL BORING# OVER-BORE. DIAMETER <br /> PRESSURE GROUT <br /> o*Other `` GROUT SPECIFICATIONS- <br /> COMMENTS— <br /> PECFCAT ONSCOMMENTS`_ T— _ <br /> �TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> `MONITORING a HOLLOW STEM DIA.OF BOREHOLEIa-12- dQy1ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 1 -7- <br /> )WXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: II STEEL�VC 0 OTHER: <br /> //a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL .kb TREMIE TYPE TO BE USED: DAUGERS 0 HOSE <br /> '117 AUR SPARGE/OZONE 0 PUSH POINT(GP or CPI)GROUT SEAL PUMPED: a Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:— N OTHER APPROX.BORING DEPTH_ VC, �o.l0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �^ , f COND^�U��CTpg]R CASIN PROPOSED— (if YES,list specifications in comment section) <br /> COMMENTS: -� (J-eC) (<04^ "�" A-d6EW-dow\ I b2 Goo II 011 <br /> 1.1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS <br /> bbbbb 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 Oons,and all applicable California State Laws, <br /> rdinan es, nd Re I i <br /> Signed x —Title/Company­ S UIF <br /> Q <br /> Print Name Date OS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: I v_ w� i I 0S hoc- h �t— <br /> It <br /> Application Accepted By Date Issued I of Z-g (D Sr Arear_ <br /> Grout Inspection By 1,1 ...�...._...... Dale I I 3 O Final Inspection By ....___. Date_jj tL(pr... <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 /> �iSo( g�•oo SS�6So SR# po jg5S9 <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />