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�� •, cq i- n Joaquin s:ounty <br /> y �{ Environental Health Department SITE <br /> 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 /> �ql/fioR��P Well Permit Application ' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSY&D�+ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work descri . hf'p pgigtioPMAde ompliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> wC:5 LA.-F- S A F-4 a: r s'ra C O tKigieYsors /-� -7 <br /> WELL Location '3230 N, W I;S 1 �-,AOv r� Cross Street Q�`gt- A—. City oc,I�oEct'J y�1 CS 6fi: ` ,1?6rcel# i/ -c&(3 1 <br /> 'Ai ENT <br /> PROPERTY 7 <br /> Owner ID4 l b,T J 4 nn}}a Address S 15 S �y �/vG�f'L City STOCi< 9/) Zip SZ/0 Phone# 2�1 9 9 2--7 6 3 V f c, <br /> C-57ContractorC SkAp Drill Address SOL,QAEC, �itde _ 'City CrApj) A Zip9S7VLLic# Pho'nee# )� �3 / 6( <br /> Consultant I Sub Cntr A.(,i (;+ Address 6S-7 6444yy A City JZQLKlUnLic# (oS©ZZ 7 Phone#Z°y) Y67--/00�0 <br /> GIS Coordinates:X 'Y Township 1V Range Section 3 o <br /> WORK TO BE PERFORMED: <br /> `&NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> a SOIL BORING# o OVER-BORE. DIAMETER <br /> WELL# M w•-�i rA VJ--S Q PRESSURE GROUT <br /> Q Other GROUT SPECIFICATIONS <br /> COMMENTS: S Q W G ,.l e Cvdv, APAO .an Z oo <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS pvl C <br /> H o TYPE OF CASING: p STEEL PVC p OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 661 TREMIE TYPE TO BE USE : UGERS a HOSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:Xes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS PORT IANC -F-/,QE - <br /> Q OTHER: 0 OTHER APPROX.BORING DEPTH (05 OLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NJA (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. A <br /> Signed x Title/Company aQ E �' /c A}y4(e/) <br /> Print Name �� Gyo1,4.eDate 09 1-13✓/ ©s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 32-30 N or+1,t West Lana <br /> WORK PLAN DATED`-:/ aT-9� 200 S <br /> Application Accepted By Y i c±or i", M c C'e r ate, Date Issued / of_ �L -0� -Area <br /> Grout Inspection By VIeirw •i <br />