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San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> 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 applicatlon is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin C unly Environmental Health Department. <br /> Assessors <br /> WELL Location 'A132. <br /> T WtpoSL `Oi ross Street kvm city JZip ar-ceRlq# <br /> PROVE Cd ( <br /> Ownerdreb �M � CITY ' /Zip0Phone#- <br /> C-57 Contractor W'ndW <br /> � <br /> /Jr� �i✓w�Addressr75o9� Ianr� Ciry E,' �is� rp9 5�/ual 7l00 Phone#70j37`/'yJ°° <br /> Consultant/Sub Cntr Slrjys C-rlvifo6ot,vf#i Adaress33?o6.nym Pork Dt.'cty5D 44(a %j7- Phan,# r�-G7/v- L? <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'lEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> a SOIL BORIN # 0 OVER-BORE, DIAMETER <br /> WELL# W— W- W-1 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS:-ahor 1T3 5C Z/^'t1i14 ✓ 1n5 )42o 5 �S <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2// <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLEby/Af u MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION u AIR HAMMER/ORIVEN CASING THICKNESS—� TYPE OF CASING: 0 STEEL 0 PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL UfViV l TREMIE TYPE TO BE USED: PIIKUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: I(Yes p No ( OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH IaSI'90 f bQfIOLTED TRAFFIC BOX or a STOVE PIPE N <br /> f� Lk 91DUCTOR CASILNG P�1t_OP-O/SEJp. flA (if YES,list specifications in comment section) <br /> COMMENTS: 4�� II �Q"1 n5f'r"K01 fY1 Q/(-�riS r,n+l *+o^ `� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 49 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 �a--a B Title/Company C9154 /Sjy�1�5 Env; <br /> Print Name f3i4nyW� Date 8-a �-os <br /> DEPARTMENT USE ONLY �^ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / AdS46& p., S <br /> WORK PLAN DATED: U <br /> Application Accepted By Date Issued b Are <br /> Grout Inspection By Date/� 9 08 Final Inspection By Dat r/o� ,Z Q Y' <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEE /7SR# Qf5J5 <br /> REC' [ A,TE PERt.!IT 1 SERVICE REQUEST# INVOICE <br /> 357n 85 $�a' ( !J <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment clot_ <br /> EHD 29-02-001 <br /> 622/06 <br />