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caul:. f"O V EDD an Joaquin Cou>Itty FILE <br /> > _ <br /> Environmental Health Department SITE <br /> East Weber Avenue,3rd Floor,Stockton, CA 95202 MITIGATION <br /> 0NM9(T1AWkL3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> ERMIT/SERV, ES <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 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. Z o y' - ys-O <br /> '}}}��� Assessors 209— <br /> WELL Location (aJ [ 1. (! Cross Street.)/Io-� i City Zp Parcel# 2-65-- <br /> PROPERTY ) _ <br /> Owner Address% Z C J rCt c c/ .3I Jd• City.'T'4tj Zip `Phone# C7 C-57 Contractor Address ZI!C )i im 4,-e-- CityS,, Ztp Llc# Phone#5lG <br /> Consultant/Sub Cntr(!)f_Y1 �a�� I7rc•_ten Address ZO /.o�� (�c�. �.Eit)�1�<<h n �• ic# Phone#7Z_5 <br /> r ;� sem.-„��-�,, ��•'�, Sri �'� <br /> GIS Coordinates:X �5 Y ! Z- Township , <br /> 1�� , 'LS Range Section y <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> SOIL BORING ZZ0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0.Other z- �Z GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> q MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 'Z 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> :VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /, TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> I AIR SPARGE/OZONE MUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ],SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ] <br /> OTHER:_0 OTHER APPROX.BORING DEPTH 3G i 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> :OMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> '.ounty Ordinances, Rules and Regulations, and all applicable California State Laws. / <br /> signed x Titie/Company sfi`��'Co.� ✓� �/�` ”y �'� ��� <br /> n v 5 <br /> 'rint Name \e n�� t /I��� Date - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> YORK PLAN DATED: —� <br /> pplication Accepted By Date Issued 3-1���5 Area <br /> rout Inspection By Date Final Inspection By Date <br /> )estruction Inspection By Date <br /> .7MMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 2� <br /> ,*n z � SRS D f <br /> WC -WAIVER C-57 Letter of Authorization to sign permit_Encroachment doc /# <br /> I-ID 29-02-001 <br />