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11 F MY- <br /> °. . �o Joaquin Couaty f <br /> �z Environmental Health Department SITE <br /> N 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd =1j L UNIT IV , <br /> e <br /> Well Permit Application //�//� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Pot 15 't ✓ '-UJ�� <br /> pplication 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. <br /> �— 116�8� �r. Assessors <br /> VELL Location-,IAC6 IaeL.D RNtr Cross Street AU1STA City !-g25K' O Zip Parcel# 033-350 zu <br /> 'ROPERTY <br /> Jwner--VM1e'SU1 QD�T Address72-0\ W WASHi Q( Ml) City­,C&&1CN1� ZIASQ3 Phon,QoC1)'M-(M <br /> -57 Contractor eorJAa`T G++)1G. AddressQZQ 0 rAs-F g-j-, City Zipjg4Li 233 Phone#a3o•660'Z4 4 <br /> :onsuitant/Sub Cntrt"flar4t iEGH -TO(— Address_695 u.c_O�k-i ► u._City,4z ��Lic# Phonei,.")�^2� <br /> 31S Coordinates:$a3"1°54. 3J . ,13L12.1! 19.091Township Range Section <br /> NORK TO BE PERFORMED: <br /> 1 NEW WELL/ BORING (CT,G)PROBE,HYDROPUNCH, HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> SOIL BORING# 5�- 0 OVER-BORE. DIAMETER <br /> 0 WELL# �G_/� / � PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> :OMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> .0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS I7 HOSE <br /> p AIR SPARGE/OZONE III PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER:_O OTHER APPROX. BORING DEPTH 0 BOLTED 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 rdinanc , Rules and Re ulations, and all applicable California State Laws. <br /> Signed <br /> Title/Company �cc-�c} �6i-�1"-c�tZli t iact-, <br /> Print Na <br /> S TC-C'..� Date IJQG.o1- t 2-210 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS; 5o f� <br /> WORK PLAN DATED: � D <br /> Application Accepted By Date Issued Area✓rr� <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 DAT PERMIT/SERVICE REQU EST# INVOICE <br /> SR# <br /> C-5/T u_' WC=WAIVER_ C-57 Letter ol�uthorization to sign permit_Encro m P <br /> EHD 29-02-001 <br />