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U, <br /> San Joaquin County <br /> Environmental Health Department o � SITE <br /> I 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ( �f1�1 [QIv <br /> " (209)468-3449 Fax (209)468-3433 Web www sjgov orglehd I Iv <br /> Well Permit Application 1,nR 1 6, 2695 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT 14CALT1 <br />' Application is hereby made to San Joaquin County for a permit to construct and/or install the work described This vPXkWTi�i� �ia pmp lance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards of San Joaquin ounty Environmental Health Departmen ' J <br /> a40 f HOR01't�a.� ffa40 Assessors <br /> PROO Location_y`]9A1, T Nu$1)�✓�R Cross Street L IM City 4�1 Zip, Sty z Parcel# C$Is"l� ��i► <br />' PROPERTY <br /> Owner Address P'O . 8r3 x /Q 5V City T I Zip 5$ Phone*( <br /> 209) 93 Z'7-7$ O <br /> AES 8AAVT SOOtr, I g0z3s` <br /> C-57 Contractor X—#-ernjjtr'w-,r,I Address'Z2 u Al, FAS-r S+ City WarD14m&_ip W714Lic# Phone# p M-7-4Zy <br />' <br /> Consultant/Sub Cntr A� G - Address F53 7 5194W/f P, City-5fa,_rC-,1,,, Uc# �Sa�z 7 Phone#_'tQ� Y(D �"�°® <br /> GIS Coordinates X 'Y Township 3� Range S Section_ <br />' WORK TO BE PERFORMED <br /> (NEW WELL/BORING (CPT GEOPROBE HYDROPUNCH HAND-AUGER OTHER`) 0 DESTRUCTION (choose type below) <br /> '' `` 0 SOIL BORING# 0 OVER-BORE DIAMETER <br />' '+SWELL# - 3 - 15 U PRESSURE GROUT <br /> 'Othe IGROUT SPECIFICATIONS <br /> COMMENTS waAK PjAA1 Aa2P.,c V^-_% <br /> r <br />' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING <br /> ©HOLLOW STEM DIA OF 80REHOLE `` �MULTIPLE CASINGS )(MULTI-LEVEL WELL CASING DIA I. <br /> (] RACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS s`ye4�le y'TYPE OF CASING U STEEL 0 PVC THER to E <br /> —� ilt,)r <br /> APOR U MUD ROTARY DEPTH OF GROUT SEAL._ u ` TREMIE TYPE TO BE USED 0 AUGERS HOSE <br />' IWIR SPARGE!OZONE U PUSH POINT(GP or CPT) SEAL PUMPED D Yes No (NOTE MAXIMUM FREE-FALL DEPTH)0130') <br /> a SOIL 13CRING Q HAND AUGER GROUT SPECIFICATIONS C %, <br /> 0 OTHER OTHER SaA is APPROX BORING DEPTH ,KBOLTI=D TRAFFIC BOX or 0 STOVE PIPE <br />' 5Tee I CONDUCTs'R CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS <OADyL}'or— Ci,;-s A9 ffo'n gAAOp 4-, <br /> INOTE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 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 /> Signedx— Title/Company U !L 11 %Z <br /> Print Name 1/M a 7+ 1 1Z J C. 149DateIV 0 y {Z <br /> DEPARTMENT USE ONLY <br /> ISITE MAP IN UNIT IV FILE,ADDRESS <br /> WORK PLAN DATED, <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destrucbon Inspection By Date <br /> COMMENTS!CONDITIONS <br /> I FE <br /> NG ONLY AID# FAC# <br /> FEE INFO AMOUNT REMITTED CHECK# REVD BY DATE PERMIT f SERVICE REQUEST# INVOICE <br /> IS R# <br /> C-57— WCC WAIVER! C-57 Letter of Authorization to sign permit_Encroachment doc <br /> I EHD 29-02-001 <br /> 6122104 <br />