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AQUrN Joaquin County • mm <br /> Y <br /> Environmental HealthDepartment g <br /> 304 Fast Weber Avenue, 3rd Floor, Stockton,CA 95202 D MITIGATION <br /> (209) 468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd u L' UNIT IV <br /> Well Permit Application DEC T 1 Z00= <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> )plication is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> ,aquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Assessors <br /> TELL Location mr, $ fie Cross Street�te. \19SSACityfi=clU0 Zip f ��el# 1 -Z'10— <br /> {, � Owt - \ll <br /> 'ROPE TY Ac <br /> )caner L kAddressN9 � �r '`�:r:.-»� City SllXi'r0� Zip9$7,OZ Phone#4)9•1cl2' �t03 <br /> -57 Contractor`t�F��^�L=r �r\Z _Address^—^^ 1 ,?f4S S1��, C""ityjll[OtAs zip�Lidl�Phone#S'3n^1jY3-2yL`� <br /> onsultant/Sub Cntr C 49MA lBt it 'TL C. Address(�`tS�.i.UrO_(7 City _Lic# Phone#7rl:i�' Z 7.(2.]l� <br /> ;IS Coordinates:kll�c7 . ,* lA P21c 19 0 9 I ,Township Range Section <br /> JORK TO BE PERFORMED: <br /> NEW WELL! BORING (CP EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION (choose type below) <br /> I SOIL BORING# 13 %U=L' 2 r 0 OVER-BORE. DIAMETER <br /> PRESSURE GROUT <br /> 0 WELL# G ROUT SPECIFICATIONS- <br /> 0 <br /> PECFCATIONS0'Other <br /> :OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> I EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Il STEEL D PVC D OTHER: <br /> ]VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: O AUGERS D HOSE <br /> ]AIR SPARGEI OZONE $,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> F SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> j OTHER: D OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or D 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 dinance ules an Reg tions, and all applicable California State Laws. <br /> Signed Title/Company !✓ IS 1 t_� -1i 'i'irGli <br /> Print Name LL <br /> Date L- �.�-�JC'�� <br /> D¢EPARTMEEN�TQUSSE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: O ✓� / -r-�"` � G <br /> WORK PLAN DATED' /1/Otl tea`/ 2 <br /> Application Accepted By <br /> Date Issued 3 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2q0! !off 0-7 <br /> 3 I sR# �D <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc/v <br /> EHD 29-02-001 <br />