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�o . q ' • �. . �a '`tan Joaquin County I f __COP <br /> _ ' z Environmental Health Department SITE <br /> y' 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 /> C P <br /> A` IFoa� Well Permit Applicatio <br /> DDb MAY 30 PM 29 52 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED V / I �/"`' V <br /> _� • `� COUNTY <br /> i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the w5 sal fd sfilftcIgtion is made in complancA with San <br /> Joaquin County Development Title, Chapter 9-11(f1�5.3 and the Standards of San Joaquin Cour TrTwoltgl gal( WPment. <br /> WELL Location o n Wes+ car �u f �'� 1 � i �(, Assessors <br /> (Cross Street (d City S1 UG zip Parcel# <br /> PROPERTYI� L r <br /> Owner?'NygrhtJ� - Qt?Address ?b 06Y I ��'� CityS-106�,Gh Zipgr))'0l Phone# �Q� I{ 61� ., � � � <br /> C-57 Contractor leS � �l'rr�1 �n CO— Address. 3lq �� (-fid ycAy�G( VIS City COYZirI'J( Zip ri ��i�Lic# K1 r4h' Phone glw� � 3� 5 /4i <br /> � ,r ,� n / c l ��p I <br /> Consultant / Sub Cntr ''M12lYIQd Crtn��IrlVl(P/�rt��l�Adres P S �'(t�'U �.d/tP CityS�hck6 Lic# CV W/z7 Phone#�Oq"4��- WD6 <br /> GIS Coordinates: X., Y., Township Range Section <br /> WORK TO BE PERFORMED: <br /> ' NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING # n I r r t r a OVER-BORE. DIAMETER <br /> WELL # AMN '• it I 0 PRESSURE GROUT <br /> *Other I L I GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING .HOLLOW STEM DIA. OF BOREHOLE K• ) '' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: �In <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN ' CASING THICKNESS r CJi t{,O TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 3(C TREMIE TYPE TO BE USED: ItAUGERS 0 HOSE <br /> 0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes b� No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Tkji it. TLIS poO lut ,&d <br /> 0 OTHER:.0 OTHER APPROX. BORING DEPTH 50 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N 0 (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 /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord//i.®n)ay//��n�c/e�ys�, R nd Regulations, and all applicable California) State L,/a' w�Is ./� r n, I} <br /> Signed ! Title/Company Myn17" 6^ e0= <br />