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WEL-t,_-PERMIT APPLICATION FytriRIIII <br /> SAN JOAQUIN COUNTY SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> 0o 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> +fir ;H (209) 468-3449 <br /> Irl I' /, y l/l." NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereJoaquin 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 <br /> rCounty Environmental Health Department. <br /> WELL Loeation SaD 4�c �rai Ry(, Cross Street V I ff p r1 Assessors <br /> City— �Od� Zip f Sa�-t2 Parcel# <br /> PROPS TY �D (011f <br /> { tOLv�n <br /> Owner roprr��cs Address � �'�S"'�f I�� CC C� <br /> /�yy f t CityJa( K" zip ! 7& Phone#qX-3 D— f,] <br /> C-57 Contractor M_Jal{1 VftilliFnvito� ! <br /> + IIAddress� 35 .G�,il�s --v(nuC City mQtL(d <br /> Zip 5 D Lich�o �Or� Phone# 7D7�lW-9p�p <br /> Consultant)Sub Cntr_Si4�5 �1V�u TN+i Addrress�'"��"" Cgwt ,m (,495682 <br /> Phone#S �i7(v-�OGZ <br /> GIS Coordinates:X 'Y City J:6k tic" <br /> ,Township Ran e <br /> g Section <br /> WORK TO BE PERFORMED: <br /> -%NEW WELL 1 BORING (CPT, GEOPROBE, HYDROPU NCH, HAND-AUGER, OTHER-) [] DESTRUCTION (choose type below; <br /> DIAMETER <br /> BORING# CO-) [3_2 CS-3 <br /> []OVER BORE. <br /> []WELL# <br /> 0*Other j] PRESSURE GROUT <br /> SPECIFICATIONS GROUT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br /> it MONITORING HOLLOW STEM DIA.OF BOREHOLEGc_t0� []MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DIA; Y1 fl{ <br /> �cc <br /> [] EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS �I-L <br /> TYPE Or CASING: []STEEL []PVC j]OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL._�Sr _TREMIE TYPE TO BE USED: ;AUGERS (] HOSE <br /> 0 AiR SPARGE/OZONE [] PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 'gYes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS nfJ yooj�u4 01 n; - <br /> []OTHER: [] OTHER APPROX. BORING DEPTH 551 <br /> j]BOLTED TRAFFIC B X or []STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED ho (if YES, list specifications in comment section) <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. p <br /> Signed x Title/Company <br /> _AC y{ C L 'fL-L1'O f�SCJ <br /> Print Name 1�� (, fJ L-s Date6 ' 4 <br /> _..__ � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By td�f\.�rol Date Issued F� 0 I i7(� Area_ <br /> Grout inspection By Date L G�lj Final Inspection By <br /> Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: L'O•P 5't< ps <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTEDCHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> f6377 1 /iq 5k 0Y-7 0(73 <br />