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w AUG 2 5 2016 ­San Joaquin County <br /> Environmental Health Department SITE <br /> m EM/IR0t,304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> ._ALT 1969)468-34491 Fax:(209)468-3433 Web: www.sjgov.orglehd <br /> UNI$IV <br /> Well Permit Application s — <br /> r^�,y <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ra O <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is mad eTn 0' lie lth San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. C,J5. <br /> ' MGI r^� g <br /> WELL Location T/,,r�S$r-�c_. O 4 _ Cross Street City Zip <br /> ParceW,�� <br /> P Y <br /> PROPER <br /> Owneri�7v' &( /-4f4oAddresq�/7r Coin'/ l ,- CityZIpPhone# 7 0 <br /> C-57 Contractor ``__!//�� ��/Address P(��Cpo �3�i City ( _ZipLic# Phone# v61�r/O <br /> Consultant/Sub Cntr /.C,&'k) Y-P/tfJr-�" AddressGaO r-17y,E City Lic# � PhoneiLj��� O / <br /> GIS Coordinates:X V Township Range Section <br /> WORK TO BE PERFORMED: <br /> VIEW WELL/BORING fCPT,GEOPR913F, HYDROPUNCH.HAND•AUGER,OTHER") D DESTRUCTION (choose type below) <br /> SOIL BORING IfW _ 0 OVER-BORE. DIAMETER <br /> ELL# +yam `- PRESSURE GROUT <br /> Other � i6��Z7 J /Z'� GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS !/ <br /> �VONITORING "-OLLOW STEM DIA.OF BOREHOLE ff <br /> /�' 13 MULTIPLE CASINGS MULTI-LEVEL WELL CASING UTA:L— j <br /> p EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS SZ TYPE OF CASING: D STEEL APVC O OTHER: <br /> a VAPOR p MUD ROTARY DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED; $,AUGERS p HOSE <br /> a AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING o HAND AUGER GROUT SPECIFICATIONS r,, �L.,a.�Sti9s,IriCy arn�d2/ <br /> a OTHER: ❑OTHER APPROX.BORING DEPTH )kCOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ' ` (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 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. �/�4/Ji,ppoo�yn— <br /> Signed x ^ TirielCompany � <br /> Print Nam cT—(J�`'yA�S' <br /> DEPARTMENT <br /> �USE <br /> -ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED- <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Deslmcllon Inspection By Dale <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# INVOICED <br /> SR# 00 2(j:�I I �:j <br /> WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment dac -57 <br /> FHD 29.02.001 <br /> fi/22/04 <br />