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*San Joaquin County 'N-uGo <br /> Environmental Health DepartmenO- 6 SITE <br /> i". 304 East Weber Avenue, 3rd Floor, Stockton, CA 952c `N`j, $ MITIGATION <br /> o P ' (209)468-3449 Fax: (209)468-3433 Web: wwwsjgov.orAi <br /> g PTA <br /> QJIN00UN UNIT IV <br /> Well Permit Application s eN�aOE 1P <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEIS <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 DevelopmgVijI 7Ch ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> `{'J J f11Or Assessors <br /> WELL Location Cross Street N1,&,4NdL3 City BRewr" Zip 1VIL111 Parcel# 0$11300 :F <br /> PROPER 'I pp / \ <br /> Owner KtJ Ycub y Address '"f S-1 lftRewougs i City SrbenrdrJ Zip 1219 Phone#li Og/f°9r�^'491/5-/ <br /> C-57 Contractor 40mA.4¢4 >W"4✓A Address S53 Ar City!L&a VIs7M Zip`/(/Sa/Lic# OO�I Phone# '� 3 - Jou <br /> Consultant/Sub Cntr "1AIFi=W`E1L- Address 9225 Z, ill SIT City SRCYm) Lic# Phor <br /> GIS Coordinates:X 'Y ,Township Range Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL I BORINGCPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> a SOIL BORING# - 2 S a OVER-BORE. DIAMETER <br /> g WELL# g PRESSURE GROUT <br /> ()'Other GROUT SPECIFICATIONS <br /> COMMENTS: GCbTCM*WrJI- 160*-- -S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE N <br /> Q I] _� ()MULTIPLE CASINGS �MULTI-LEVEL WELL CASING DIA:�_ <br /> a EXTRACTION g AIR HAMMER/DRIVEN CASING THJCKNESSSCA 140 TYPE OF CASING: O STEEL KPVC G OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: xAUGERSa HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes 4LNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS /JCNT c8wes t' 1%IG Iii /S'- JrAftN Q) <br /> OTHER: � OTHER APPROX.BORING DEPTH o4T'It- p BOLTED TRA IC BOX or kSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: 03W TUP- VAtE4-t,PaW eeJy <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 v 7"� Title/Company Z A6 ,hE&, <br /> Print Name , Yz.71 S ,f Date 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 7 h do.(o Area��� <br /> Grout Inspection By —Date-2 TL Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMITISERVICE REQUEST# INVOICE <br /> dq- <br /> D no ��b" f N7 !� (y0 1k & SR#� t7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122104 <br />