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�� �� k-061-an Joaquin County <br /> yr• <br /> onmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> � X468-3449 Fax: (209)468-3433 Web: www.kigov.org/chd UNIT IV <br /> �V1t�0�i�R�hiT 11E��.Tl�I Well Permit Application <br /> EI <br /> PERIAIT/SERW&FR�FUNDABLE 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 Developmeni Title,Chapter 9-1115.2 and the Standards of San Joaquin County Environmental Health Department. <br /> ;Z 80 W , L- ,1 `1.93'1 b Assessors <br /> WELL Location + n�.e Cross Street. �1.4J City �t c� Zip . Parceltl S Q 0 3 <br /> PROPERTY <br /> Owner 9z cam . SN fic�A.r Address l lnl . 2_:�,.,,� city.�5'r c a <br /> l 1632- 151-7 <br /> C47 Contractor S�^N-<–Address ZZ G `�s� S� Giiy Zip 0.S LEr Phone# 5 10 <br /> C sulfa l Sttb-tepV_�e i��t j°z rg g Tr 1,�cc 4ddreSS 11V �. flet S Grty�'6�yre CS i_IcA` f'Iterteii I V 9 S Z 1 '41 <br /> GIS Coordinates:X Y. Township _ ��Ran4e Section <br /> RK TO BE R <br /> I NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') al STRUCTION (choose type below) <br /> 0 SOIL BORING#_ <br /> Q WELL#'I TV-,v3 ► Q OV ,SORE. DIAMETER <br /> n`Other, Il PR!_S5 E GROUT <br /> GROUT SPI; CATIONS <br /> COMMENTS: :t �szs�-.. 01 Z6-- o'� <br /> TYPE OF A LL �I INSTALLATION-TYPE CONSTRUCTION SPECIFICATIONS <br /> 41 MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: _ v <br /> EXTRACTION AER HAMMERiD121VEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC I1 OTHER: <br /> 0 VAPOR 'I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 8 AUGERSa HOSE <br /> n AIR SPARGE)OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes U No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') f <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS r <br /> o OTHER: l n OTHER APPROX.BORING DEPTH <br /> a t30LTED TRAFFIC BOX or [I STOVE PIPE �- <br /> CONDUCTOR CASING PROPOSED (,if YES,list specifications in comment section) <br /> COMMENTS: <br /> I <br /> t4 <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> j 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 Ordina ceS, Rules and Regulations, and all applicable California State Laws. <br /> Signed x- _ !6,;. �_ ��� <br /> - TitlelCompany �cc_ ��-r�,��.. <br /> Pont Name �Jt^y�. f i vZeL r •-.tee_ Date <br /> f DEPARTMENT USE ONLY r <br /> SITE MAP IN UNIT IV FILE,ADDRESS: b <br /> WORK PLAN DATED: Ct S-tl p <br /> �I I <br /> Application Accepted By l/�-tom" Cxn,� Date Issued I "Z /C).5r— Area 6 2L Cj <br /> Groat inspection 8Date 3 1'+ b`> I incl tnspection By 'Of. Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: yy <br /> ACCOUNTING ONLY: AILD# FAC# 3 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECID.SY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> SR# <br /> 10Z--( <br /> C-57� WC,�,-WAIVER C-57 Letter"of Authorization to sign permit Enct^nctchtnerlf doc <br /> EHD 29-02-001 <br /> 5!22104 <br /> I <br />