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�uFD <br /> San Joaquin County <br /> A `- Environmental Health De artmentSITE <br /> AN JO <br /> COUh1 <br /> ¢:. � -1 p ENVIRONMENTAL <br /> " 304 East Weber Avenue, 3rd Floor, Stockton,CA 952 MITIGATION <br /> , KITH DEPARTMENT <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ebd <br /> UNIT IV <br /> Q��FOR <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ?-I OBD q �6 Assessors <br /> WELL Location i 5, kr-,�t I f-t t Cross Street City /r✓{ Zip el# 12111 1? <br /> 3� <br /> PROPE <br /> Owner I e to rt a. Ts ld, /Zf 11lAddress: /A 40k 9 7 City 4 0 1¢ Zip Phone#2-10q <br /> C 4-550 C- <br /> C-57 Contra to Notqur r1 I ct hcr,n n Address life c L-e,, r S f'. City OPange- Zip 92$67Lic#b523(nPhone#7/q-210-1-7( <br /> r fi eeTSAV- <br /> yCD <br /> Consultant/Sub Cntr H u 1+o rr en- ( t I(I•$ „ Address_ 2 L I ��rr t-.Erne- Cith(o rj Lic# Phone#R -S-685-so <br /> GIS Coordinates:X l TO.7(02Jn, 3 ,Y ZI 2-Oho0Q-j ( ,Township Range Section <br /> WORK TO BE PERFORMED- <br /> /VNEW WELL/BORING (CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> SOIL BORING# ('_ `��Q VeT_ Q OVER-BORE. DIAMETER <br /> a WELL# 0 PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: r ea-f -ror( <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING [)HOLLOW STEM DIA.OF BOREHOLE 1]MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Il EXTRACTION 11 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL PVC a OTHER: <br /> 0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: Q AUGERS HOSE <br /> [IAIR SPARGE/OZONE x <br /> PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'Yes [I No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS Cy tot, Co � <br /> OTHER: fl OTHER APPROX.BORING DEPTH Z Z�-�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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin ces, Rules and Regulations, and all applicable California State Laws. <br /> Signed x / L Title/Company //Vc J� E G <br /> Print Name ��/ �/ S M � L(_e/-e- Date_ — e <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILEDDRESS: Z 1 oc� y tom)• Sf- (L-f -`7' <br /> WORK PLAN DATED: -t- 12-o v 6 <br /> Application Accepted By Civ.-- Date Issued �'2---f/oc=, Area <br /> Grout Inspection By (11 AAC111-- Date Z- o Final Inspection By �"�VVv`��-✓� Date � 2 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: ( Z D6 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> a �o! { � .c�o ro!� } Ly1o� SR# <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br />