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U <br /> an Joaquin County 4AYMENT <br /> Environmental Health Department RELIVE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202\ SITE <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UN 2 8 20MITIGATION�\F p R�`p' • SAN JOAQUIN COUNTY U N I T I V <br /> Well Permit Application ENVIRONMENTeI <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED HEALTH DEPARTMENT <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 /uyg,,'I 42, Cross Street_ City 5704091 Zi 9sszr <br /> Assessors <br /> PROPERTY p�_Parcel#_Q77/_5e' <br /> Owner—42-M JIII94AIV <br /> —Address 29p <br /> 7Atlrk: D0., City SysckrwJ Zip J�Phone .zo$ _ <br /> C-57 Contractor yLp ALr 'X Address 3-1 <br /> 40 R..Fa_. Dawn <br /> Consultant/Sub CnV !e.>,,,rf�.� City uustp Zp 9ypq/Ligx oo'0Phone# sq¢_ cm <br /> Address39Lf' E sr.s>�a 'r .f <br /> GIS Coordinates:X CIty-�LIc# PhoneC2o4 g,rs_-1i c% <br /> —� Y Township_Range_Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT, OBE,HYDROPUNCH,HAND-AUGER,OTHER`) Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# <br /> Q WELL# Q OVER-BORE. DIAMETER <br /> Q Other Q PRESSURE GROUT <br /> COMMENTS:- GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE <br /> EXTRACTION -5A Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2�_ <br /> Q QAIR ROTARY <br /> CASING THICKNESS <br /> Q VAPOR Q MUD ROTARY TYPE OF CASING: Q STEEL kVC Q OTHER: <br /> DEPTH OF GROUT SEAL ` TREMIE TYPE TO BE USED: <br /> DAUGERS 1]HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Oo (NOTE: MAXIMUM FREE-FALL DEPTH S 30') <br /> Ir <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> AOTHER:&22—_- �OTHER . bl LTD •- /c SZ/I <br /> APPROX.BORING DEPTH ��4i. � I <br /> Q BOLTED TRAFFIC BOX or <br /> TOVE PIPE <br /> COMMENTS: VSCO q" "fvt73 cJ (if YE <br /> CONDUCTOR CASING PROPOSED S,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 /> �l Title/Company AZ <br /> Print Name <br /> Date_ 6�Lp9 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /J r <br /> Application Accepted Byt /,t�Il-1' / <br /> Date Issued �t'� 0to <br /> Grout Inspection By 6%11E,�-,.p-Q_,Q ute'7 r� �/ Area <br /> Destruction Inspection By I Inspection By Date <br /> Date r— <br /> COMMENTS I CONDITIONS: <br /> III <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PECODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 9.01 ' e?O <br /> C-57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/2J04 <br />