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ECS `TI'u EE D On Joaquin County • FILE COP Y <br /> 22�r1�r1Environmental Health Department SITE <br /> UG 4 �f ast Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> IRONMM"0@f*49 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> o PERMIT/SERVICES Well Permit Application LG <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D 1 1 — efT.5 <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 compliance with San e <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> -mss E �,eST. ST _/Cross Street ty R/Oa(✓ Zip 536 <br /> As <br /> WELL Location b <br /> /l/��lSJIli4C.Ci q 6 Parcel# ZS93�io1 <br /> PROPERTY <br /> OwnerDRyrp 6, SANDER] Address P,O,goX 365 Ciry LLfV Zip`f 36k Phone# <br /> C57 Contractor GrerDrq,r. _Address `1S0 Howe Pd. City2427n4eL Zip9yK3 Lic# 6`?640}Phone# g�-313-5800 <br /> Consultant/Sub Cntr Geos rA'frrx Co-✓✓ I Address 2/0/ WFifife St 14'tr CitygdL2- b Lic# Phone# -570 663-Y2/9 <br /> GIS Coordinates:X 14yQ310Q ,v, ,Y `15)bZoa ,., .Township Range Section <br /> L-AT, 3}; y4- l4N Low' l2/; 03 igW <br /> WORK TO BE PERFORMED: <br /> )(NEW LL /BORING (CPT, EOPROBE YDROPUNC HAND-AUGER,OTHER•) p DESTRUCTION (choose type below) <br /> SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ELL# p PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: (021 horrv3S fo )20 flat bSS;Z__ ('A2L' imik IyFjrTIDE <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 /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP o CP GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AtOIL BORING aHAND AUGER GROUT SPECIFICATIONS AN& NO+(' (na•vof tinsCj- <br /> AOTHER: fl OTHER APPROX.BORING DEPTH 12 a -re-et p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /I _ _ CQNpUCT R CASING PROPOSED (If YES,list specifications in comment section) <br /> .COMMENTS: �/ �pT-�� <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. <br /> Signed xn),i Title/Company�014f-�G,.. 1 I x L��'�, S <br /> Print Name Date �s I°5 <br /> DEPARTMENT USE <br /> ONLY n <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 1-.3 'Akdu-- t a4'.f. uwU/4cb 640 <br /> WORK PLAN DATED: Z-O f < �y <br /> Application Accepted By Date Issued O Z 3 / Area 0'y�n i <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> ?-Qo 1 ?q. -- ®?i V'3 ?- 13 SR# &)413 6 Z1 <br /> C-57C-57 Letter of Authorization to sign permit_Encro lment clot_ <br />