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l <br /> — Yan <br /> Joaquin County <br /> nvironmental Health Department SITE I <br /> ® 247 <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 MITIGATION <br /> 09)468-3449 Fax:(209)468-3433 Web:wwW.SjgoV.org/ehd UNIT IV <br /> ;v "£ 1 HEALTH Well Permit Application i <br /> PERMIT/SERVICENON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED i <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 co <br /> mp)lance with San <br /> Joaquin County Develogmeat TKIe,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.�tcv4rJ Assessors <br /> WELL Locatio Cross Street S' Ci . JJ V) Zi -(u <br /> ty �L p Ue5 Par <br /> /' - <br /> - r <br /> PROPER I ((� p �i/ <br /> Owner Et llryt Address a� , �lt' ! City�5_ rr_Zip 7rZdZ Phorw� . ��U�.137-Y3�6 <br /> + �yrl(�1 U� <br /> C-57 Contractor SCUG(� rl��kr+c ,�(,Add�rhes__3{Q�a Q"�1�C �i�[)� Ciiy _Zip���q�uc#Q'!^1I- to Phone#-31(�-638-.(1�G� <br /> Consultant IsubCe�� w�v� r� �v1i�'�'i-,'I"4"Y1!� �y�Dl ulfi 4 �516dC � r ZS+ C <br /> t 1 Address Yt"eW°�1 r G`r��r� City�Qv" gin LEa� Phone#✓3V"67� <br /> GIS Coordinates:X Y Township Range Section <br /> tN RBE PERF i_D- <br /> EW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) D DESTRUCTION (choose type below) <br /> a SOIL BORIN # a OVER-BORE. DIAMETER " <br /> &.WELL#�Ec1—iy� -MIN-1`I c .�1ViT1 0 PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS: A-VI49 5UWLt, LP2:. I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING OLLOW STEM DIA.OF BOREHOLE_!. U MULTIPLE CASINGS 'a MULTI-LEVEL WELL CASING DIA: Z�� <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS " ,L?0 " .TYPE OF CASING: a STEEL }',PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS HOSE <br /> a AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,'Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH .30') <br /> a"SOIL BORING a HAND AUGER GROUT SPECIFICATIONS rlam_ <br /> a OTHER: B OTHER APPROX.BORING DEPTH1SF )'BOLTED TRAFFIC BOX or a 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 O inances,Rules and Regulations,and all applicable California StaIl <br /> a Laws. <br /> ci L r�c <br /> Signed x . 1✓UL t`< � _ TitWCompany S4Ya5 F'lv;rjnli � i .7Rr." t t�C'c`���E 54 <br /> Print Name _i 1 JA 44'1_ Date 1�� !_o:1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: b� S ✓�e.C ' S td �.5�. Sri t ""t "s"fc" . � <br /> WORK PLAN DATED:L D 5_5 <br /> 4,11 <br /> Application Accepted 8 -1 Date Issued I' 11 1 V-7 Area <br /> Grout Inspection By _ Date ,14.'!�7Fina!Inspection By � Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: MLY (a I `� 1 d C•b,S• Lv <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> SR# 5Ice <br /> C-57 WC--WAIVER_ C-57 letter of Authorization to sign permit Encroachment doc� <br /> EHD 29-02-001 <br /> 5/2Z/p4 <br />