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r <br /> a•H kan Joaquin County - <br /> =WN <br /> �.a� Environmental Health Department SITE <br /> P'y- <br /> ' "' xm 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> r (209)468-3449 Fax:(209)468-3433 Web:wWW.ajgov.org/ehd 1V <br /> Well Permit Application <br /> fim;r � <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor inetaa the work descrlbad. This application Is madeS pl hark&Ih San <br /> ' Joaquin County Development Title,Chapter <br /> J9-1115.3 7and the Standards of San Joaquin County Environmental Health Department, d e- <br /> i4k� In <br /> WELL Location J/ 1J55 9 l/IGLF-�,.< Cross Street city ZiPftL-?;) Pasrcew <br /> ' <br /> PERT / <br /> Owner Addrsm&?,` - '!(GUS:.' City_. 21pj!:�Phone# Own <br /> C-57 Conlraclar <br /> ' Consullantl Sub Cntr L:�:l� y-N�k`rXi'— Address r �{� 'rr+ <br /> GIS Coardinales:X V ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ' 'ANEW WELL/BORING jCRPT.GEOPROBF,HYDROPUNCH- 0 OVER-BORE. DIAMETER_ <br /> WELL#_ &p Q PRESSURE GROUT,r$ /'ZP Z-� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ' V IONITORING "OLLOW STEM DIA.OF Q EBOREHOLE <br /> ''''aMULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA:1r, <br /> XTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESSgy'f TYPE OF CASING: 1]STEEL Vvc Q OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL_S-l_TREMIE TYPE TO BE USED: X.AUGERs Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yea o (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS pyo (r�lg aC9, Jfr <br /> ' Q OTHER:_ _Q OTHER APPROX,BORING DEPTH_ l EOLTED TRAFFIC BOX or Q S7OVE 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 Ordinaann'cees,Rules and Regulations,and all applicable California State La/ws. <br /> Signed K t'.� !�s/l�-"�'' ) TitleiCompeny /.�'t'�£ S G.�I�LF.•r �- . <br /> Print Name // a'-"�.?11� - Date <br /> DEPARTMENT USE ONLY <br /> ' SITE MAP IN UNIT IV FILE, ADDRESS; <br /> WORK PLAN DATED: <br /> ' AppNcaflrxi Accepted BY _ <br /> Dale Issued- Area,,,,-,`'� <br /> Grout Inspection By Date Rnal inspection By Data <br /> Destruction Inspection By Date <br /> ' COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: A;D# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'o BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> r <br /> C-57V WC_ WAIVER_ C-57 Letter of Authorization to Sign permit_Encroachment docAor 6'6— <br /> ' EHD 29.02-001 <br /> 6!22104 <br /> t <br />