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San Joaquin County FILE COPY <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 /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 com ance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 qnd the Standards of San Joaquin County Environmental Health Department. <br /> ee?1 i <br /> Assessors <br /> WELL Location If Al, /��- x/ dr:"Z Cross Stree1479 �t City 5�crl�/c,� Zip �r-?05 Parcel# <br /> PROPERTYf S,Iw l D:s�rrcf <br /> Owner Address I4N4 Cityn Zip q���S-Phone# Z09 ` 3 %� <br /> C-57 Contractort✓r� Address 1S-0 it-ter /14•1NMOP City� ����e�Zip`r'y ,?Lic#9S'5-/6SPhone# <br /> Consultant/Sub Cntr 81&e.5 .+v,ir.yNe. TF/Address IY3.3 N. kik 4,,zc City phi'-,x Lic# Phone# Ze Z-7���-�' <br /> GIS Coordinates:X N14 'Y Nei .Township -VZ hJ Range k 6 E Section 3 r- <br /> WORK TO BE PERFORMED: <br /> g-NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# U P <1 DOVER-BORE. DIAMETER________ <br /> DWELL#_w-/�M h.-13 C a PRESSURE GROUT <br /> 0`Other pGROUT SPECIFICATIONS _ <br /> COMMENTS: ! Ok D 11-70017 rr�� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> $MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS <br /> 0 MULTI-LEVEL WELL CASING DIA:�_— <br /> p EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 15t( TYPE OF CASING: Q STEEL XPVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL-ieoc TYPE TO BE USED: $KAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE'ZPUSH POINT(GP or(j�f)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Ne, Cr..Q I�d-e <br /> 0 OTHER-___a OTHER APPROX.BORING DEPTH °15. S^ 6SbLTED TRAFFIC BOX or <br /> 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: SfP f} t.c�10 t1/e.l� I�t`a q+ «»,5 i 11 �yP�fiyiert+ ✓77u� / cr <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. 1 <br /> Signed . l ,,if`- '/� _ Title/Company Ay"CfLtA t`�A-,A t��� / ':iq iM1+Q-�}ktYv <br /> Print Name�tX-,A K Frt k - Date Z`Z <br /> -- ----- <br /> SITE MAP IN UNIT IV FILE,ADDRESS: DEPARTMENT USE ONLY 1-400�'�l /V• � <br /> WORK PLAN DATED: Z- -O b ' <br /> Application Accepted By Date Issued - Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT <br /> AMOUNT REMITTED CHECK# RREC'D BY DATE PERMIT!SERVICqREQUE;STj# CEMA � �35 [ jk SR#C-57WC -WAIVERC-57 Letter of Authorization to sign permitEnc�meEHD 29-02-001 <br /> 6/22!/14 <br />