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PCt,V�N c FILE COPY <br /> 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 /> %FORa Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> >pplication 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 /> Assessors <br /> '' � � Pvu� , <br /> WELL Location 2Street IZpY <br /> Parcel# <br /> I►'l�. Ifo v s� �k-w� Pk MI. Ff�SL <br /> PROPEJR ` � <br /> .203-5— <br /> Owner <br /> 0 3 � <br /> OwnerzAddress Cityna { ZiP Phone# /-174 <br /> r3L <br /> �) �---- <br /> I: y:r ^ ,,I, 'j— / r-601c � '-Phone# C�3]) <br /> C-57 Contractor Address 3 6 I/ ��� P�/...s CityTTd t ZiP� <br /> 4roj <br /> Consultant/Sub CntrG1&4 a,.,, fsr„ZeAddress jj j 2d 11 C D,j i City► Icw6A��o Lic# Phone# F -y2s-� <br /> P , Si-e f-r(' <br /> G15 Coordinates:X <br /> Y ,Township 21 f Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WErLL a BORING . rrcr nFnpRnHYDROP�UN'C00 PRESSURE GROUT <br /> H,HAND-AUGER, DESTRUCTION (choose type below) <br /> ,OTHER') 0 <br /> NG#_ �ico�,+� do><< G� � OVER BORE. DIAMETER <br /> / / J <br /> �f GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z” D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE. <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nd•- k<01 je" " T ^ 4-. 7L`{ <br /> 0 OTHER: OTHER / APPROX.BORING DEPTH G 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certif4thatl prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordind Regulations, and all applicable California/State Laws. r <br /> Title/Company <br /> Signed x — �• �J <br /> Date_�1�� <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: N <br /> WORK PLAN DATED: J <br /> Date Issued /L 7 Area D <br /> Application Accepted By <br /> Grout Inspection By <br /> Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> 9C-575W -WA <br /> AID# FAC# <br /> AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 SR#IVER_ C-57 Letter of Authorization to sign permit <br /> Inc o <br /> F,gn'19-02-Q I <br />