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In 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 /> d. This <br /> plication is mad <br /> JoaquiniCounty Development Title,IChapter 9oaquin -11 5.3 and theunty for a !Standards of Sat to construct o Joaquin ix install <br /> County Envithe work ronmental Health Department.Assessorsj <br /> insorsj compliance with San <br /> I1 J „I 5�( Zt ) Assessors aq��5 <br /> WELL Location o-ISI !""fit r0� �(/� Cross Street /ml /�(�'/ ity C, '/p Ss4v Parcel# I�� <br /> PROPERTY !Yr/) aC �/,t/I 0 �G CityZip IJ��'1 Phone# <br /> Owner I''II <br /> pip Y Address / /j /�� rl <br /> C-57 Contractor AVO W I�frGll � Address 55c, V,' //""'tc City I`/u �,jjq Zip 9y5jucx_20U� Phcne#?U7-37`�-y��0 <br /> Consultant/Sub Cnlr s�'fWNS L;✓IVi/oVl Atli Address 33?O IAr+IVwl Ph^k p/.JCty Com4^1 PhIC Lic#�G�Z Phne# �°-7�' b2 <br /> GIS Coordinates:X <br /> y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ODER OVER-BORE. DIAMETER_(choose type below) <br /> [)SOIL BORtIJG# 0 PRESSURE GROUT <br /> LL# �n w"1 /')11.V^IXC_—.— GROUT SPECIFICATIONS <br /> her --� <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING �IOLLOW STEM DIA.OF BOREHOLE 0 n MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:Z <br /> '; <br /> n EXTRACTION u AIR HAMMERIORIVEN CASING THICKNESS `)A,yU PUC R <br /> TYPE OF CASING: 0 STEEL PVC u OTHER: <br /> n VAPOR 8 MUD ROTARY DEPTH OF GROUT SEAL Vwr TREMIE TYPE TO BE USED: O AUGERS a HOSE O <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ''res, 0 No ( OTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING 13 HAND AUGER GROUT SPECIFICATIONS <br /> ullum <br /> Q OTHER: n OTHER APPROX.BORING DEPTH 90 �51 0 BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED AA (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. T <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. 1 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord' antes, ules and Regulations, and all applicable California St/ate Laws. �� <br /> S OD TitWCompany �d 157 /5445 F nv: n mr A "" <br /> Signed x <br /> 5 +1 �I 1.� Date 8-a -os <br /> Print Name hN�� IO 17 I <br /> DEPARTMENT USE ONLY - <br /> SITE MAP IN UNIT IV FILE,ADDRESS: x-13 Z yytry ys°s 1 SZ o C <br /> WORK PLAN DATED: k,-4 tp`� ZDU 5t <br /> Application Accepted By ^A Date Issued //�/U 8 Area 9q7 <br /> Grout Inspection By Date/u (, Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFOAMOUNT REMITTED ^HECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> --�1�,OI $1 q91 <br /> _l ?u 8U lf?V- t! s8 SR# r< 7,-3 - <br /> C-57_ WC---WAIVER— C-57 Letter of Authorization to sign permit_.Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />