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kk <br /> J <br /> San Joaquin County <br /> tY <br /> Environmental Health Department fi. SITE <br /> lift, 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 Zaps IfAY 18 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p� <br /> plication is hereby made to San Joaquin County for a permit to construct and/or install the work deacnWd This aMAR <br /> liar-ce with San <br /> Paquin County Development Title,Chapter 9-11115��3ppand the Standards of San Joaquin County Environmental Heal �� y <br /> WELL Location^"Cm� Cross Street j&=hC0& City ZapParce 0 2z- <br /> ROPER W Q 610(f1�+1 WA <br /> afS_ Address IDZy lik l �City.�kCCUovnk Zip7�)jxPhone# rlC! <br /> -57 Contractor��rSk&135%�Address 2Ao52 CxyLQC 6M4l?_ City Zipjjjj Uc#ffjjfMPhone#.%tojo3_?!l t1,k0q <br /> ons ultant/Sub CntrAddressjocal A ilckraftyujig City5=mapA&Uc# Phone#Qll(c 3CDn'1 ?IOQ <br /> t0 <br /> GIS Coordinates X Y Township Range Section <br /> LORK TO BE PERFORMED <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH HAND-AUGER,OTHER') I]DESTRUCTION (choose type below) <br /> 0 SOIL BORING# d OVER-BORE DIAMETER <br />' 4NELL# PitS 13 PRESSURE GROUT <br /> J'Other GROUT SPECIFICATIONS <br /> COMMENTS =^1=2 ll A Ir_at`aP_ WeA t Att-16 3 ct ronnup yn au%letrn l iv a <br /> IyPg QF WELL INSTALLATION IYPir CONSTRUCTION SPECIFICATIONS <br /> MONITORING ISHOLLOW STEM DIA OF BOREHOLEQ,'A$0 MULTIPLE CASINGS (I MULTI-LEVEL WELL CASING DIA <br /> WR <br /> CTION 1]AIR HAMMER/DRIVEN CASING THICKNESS&& *jf"CYPE OF CASING IISTEEL XPVC IJOTHER <br /> (I MUD ROTARY DEPTH OF GROUT SEAL SO•i TREMIE TYPE TO BE USED t]AUGERS CHOSE <br /> ARGE/OZONE [)PUSH POINT(GP orCPT)GROUT SEAL PUMPED )KYes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS NMAT <br /> OTHER 13 OTHER APPROX BORING DEPTH q\1 BOLTED TRAFFIC BOX or (]STOVE PIPE <br /> Ie f CONDUCTOR CASING PROPOSED ]yt'� (ii YES,list specifications in comment section) <br /> OMtMENTS 0 -90 <br /> 140TE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certifV that I have pld <br /> pared this application and that the work will be done in accordance with San Joaquin <br /> unty Ordi n , Ruh s a Regulat ons, and all applicable California tate Laws. <br /> Ar <br /> IIg x , /AAP Title/Company <br /> rint Name U a liQ �/V Date <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE ADDRESS: .5)(0615-60,0 f' $ 1 <br /> WORK PLAN DATED: <br /> plication Accepted By t7ate Issued ^31 ___Area d 6 <br /> rout Inspection By Date Final Inspection By Date <br /> Destruction Inspection B Rafe <br /> MIENTs!CONDITIONS <br /> WING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> �a r uI �zs �Is SRS oasiz. <br /> -57 WC;WAIVER r C-57 Letter of Authorization to sign permit Encroachment do <br /> c44 <br /> x <br /> I:HD 29-02-001 <br />