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-.n Joy jinni County <br /> A Envirk,'mental Health Department SITE <br /> y 304 East Weber Avenue. 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov �'ebd UNIT lu <br /> A�lFORa 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 /> WELL Location 72'2q Cross StreetAssessors <br /> er S,t�' +: City S �)� ,.� Zip lc;zr.<< Parcel# <br /> PROPERTY <br /> Owner 0A.1,.1, 3. <br /> Address 2-2244 dvl...r cw City �5+r•c �Fc n Zio cSZr'/ Phone#/2c,",)'1(,Z-7l,ZI <br /> C-57 Contractor(L'/i=nyF- 2c, ,o Address s>;-� �,• a r City S, ,J, , Zip gSZlS Lic# Phone# <br /> Consultant/Sub Cntr A�m�roO (^-�,� ', ,�Address City +. {,r,^ Lic# 6-,yC.2 2'1 phone# (7�f�-lC.c�Cc <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED• <br /> X,'NEW WELL! BORING (CPT,(EOPROBE,HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (choose type below) <br /> 00 WELL#SOIL BORING# 0 OVER-BORE. DIAMETER <br /> O'Other 0 PRESSURE GROUT <br /> GROUT SPECIFICAT <br /> COMMENTS: ow- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE I Z�;" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS b/c TYPE OF CASING: <br /> 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL LI5 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE •PUSH POINT(GO)o,CPT)GROUT SEAL PUMPED: 0 Yes /gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> � <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX. BORING DEPTH y S` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED ,/,_ (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. <br /> Signed x <br /> . " Title/Company : <br /> Print Name ` T I C Date <br /> DEPARTMENT USE ONLY j <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 2 22 4 M,2 Y,4 h e v -.RG Qat <br /> WORK PLAN DATED: 26 26 .20ti 7 <br /> Application Accepted By_v 1,a*6';.a j N1 eZ4) }- I Date Issued --2 S' 6 7 Area 1 <br /> Grout Inspection By Dah 1,te ?- !3-b 7 Final Inspection By V.-frf i A Z, !)i��'i��anl.+Date 7- / <br /> Destruction Inspection By Date ��JJ <br /> COMMENTS/CONDITIONS: �r VDrt��m �,�1 43 13 10 <br /> FACCOOUNTiINGNLY: AID# FAC# <br /> EEINFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 4 aS'7i0SR# 665 o 74.8 <br /> C-57_ WC--WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> ry')')in A <br />