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NoSan Joaquin County R° �'CLQu�EDPEnvironmental Health De artment SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,(AMA22.2 2006 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: hd UNIT IV <br /> � iVTHEALTH <br /> Well Permit Application PERP,ej1'T/SERkgES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County fora 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. `� t <br /> Assesso <br /> WELL Location,) S S4A15 Cross Street J!% City Zip Parcel#rst'T 3'Zg g"/Z,,,, <br /> OwnnerE j Address b I' s.- 1 City ZAS115 Phone# X13I-S��- <br /> QQ,,� f(A 2 9 <br /> C-57 Contractor f� Address - T�)( n//V-1 J City 0 t Zip Li77w7Phone# c <br /> Consultant/Sub Cntr Address au Z. 'est City Lic# Phone# —'?✓ 7 <br /> Do 9 139225, <br /> � <br /> GIS Coordin ® 11L 13 12 0o7,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROB�HYDROPUNCH,H ND-A G R OTHER*) ®DESTRUCTION (choose type below) <br /> a SOIL BORING#S I i-h La*d 5 L . BGS f— I;" a OVER-BORE. DIAMETER <br /> a WELL# V <br /> CY(1 thfar�� rN� R E GROUT <br /> a*Other /GROUT SPECIFICATIONS <br /> COMMENTS: 4 M 111AWAA AJ 2 `/1CAV <br /> TYPE OF WELL INSTALLATION TYP . CONSTRUCTION SPECIFICATIOj <br /> ®MONITORING a HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE C/A�ST ®MULTI-LEVEL WELL CASING DIA: <br /> ®EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS TY k—CASING: o STEEL ®PVC ®OTHER: <br /> ®VAPOR a MUD ROTARY DEPTH OF GROUT SEAL S CCTREMIE TYPE TO BE USED: ®AUGERS a HOSE <br /> AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes V to (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: a OTHER APPROX.BORING DEPTH / ')t O ®BOLTED TRAFFIC BOX or ®STOVE PIPE <br /> 1 / COND CTOR CASING PROPOSED JU A (if YES,list specifications in comment section) <br /> COMMENTS: (� ��^PYt 1 (1 122(A.I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby c l"th 1 ha prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or anc RuI s and Regulations,and all applicable California State Laws. <br /> /f <br /> Signed x Title/Company W e0 r�-• <br /> Print Name ® Date Lt l0 (0 <br /> DEPARTMENT USE ONLY <br /> bt5G <br /> SITE MAP IN WOW FILE,ADDRESS: 'K 5 +z to t S Iw ti a, .114 <br /> WORK PLAN DATED: q L DS ( r <br /> Application Accepted By (A>Vk vecG r-. Date Issued q 1 L44 10!1 —Area 2� <br /> Grout Inspection By Date Final Inspection By rte_ Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> x�o t � gR.oO i 2T1 y q jtq/e=SR11 "t//& 5 b,7 <br /> C-57s WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />