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• • FILE COPY <br /> ,o p 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 MAR 2 7 Pit I LUT IV <br /> Well Permit Application <br /> SAN JGAriC�iPd C(1iJitT'l <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE E N d I l�ON HEN T A L <br /> REALiFiDEPARTHENT <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 evelopment Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> u�'Apa 'L 5p T Assessor A Ot / <br /> WELL Location . r, ' !J . I Cross Street City G Zip Parcel# G �(/ <br /> PROPERTY D GSY r Qfj )r� QCycaf-t'o A44K Park c± f <br /> Owner Address J_�y 1� yt City Zi�pZ,�4_Phone#.7Ol��3Z—yq//g <br /> C-57 Contractor A Address3�i l�Nc:.e D Phon,#yRf6-pti3� ll <br /> Consultant/Sub Cntr SAIL Address31Q9 Wei;My.'t to City — ( iic# Phonei�/ - C� <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) DESTRUCTION (choose type below <br /> 0 SOIL BORING# OVER-BORE. DIAMETER % i q�) 9 <br /> 0 WELL# PRESSURE GROUT �� V FAr <br /> 0.Other GROUT SPECIFICATIONS ee /t <br /> COMMENTS: ALA, gAel� t �Lf'f� /117' 2�/tllt 131'�t %� I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u <br /> I �'MONITORING 0 HOLLOW STEM DIA.OF BOREHOLES�� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 'J[PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ✓3T TREMIE TYPE TO BE USED: �AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP orCPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_ YIG�L/'l��wPx-F <br /> OTHER: V49121O OTHER APPROX.BORING DEPTHIT� 1 %/ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> cCaL�ON/rDrU�CSINGb PROPOSED <br /> r- fAIl- 4�jX1e_l�istt tspae_c..ilfi7caKtioCn-is, mszec/tiron) <br /> COMMENTS: tOoc <br /> NOTE: 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 /> Signed xx�r��---�-! Title/Company�Ior <br /> Print Name a ryLP✓'e Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL A DRESS: .0-9t-6 /U• (/�Q (��iL!/�� J 9 66 <br /> WORK PLAN DATED: %Zb d .L/'0 <br /> Application Accepted By Date IssuedZ� Area &7b <br /> Grout Inspection By Dale Final Inspection By <br /> Destruction Inspection By _ Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC' TE PERMIT I SERVICE REQUEST# INVOICE <br /> Aa Al2 6a. ( 091 3 sR# ® yz <br /> C-57 WC=WAIVER_ C-57 Letter of Author, ation to sign permit Encroachment doc_ <br /> EHD 29-02-001 <br /> 622/04 Ddv-*6/' 34) <br />