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• "'" �a San Joaquin County <br /> 12 ? Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)463-3449 Fax (209)465-343IUNIT3 Web �ww-w s�gov org/ehd UNITI <br /> CQ( <br /> `FJ Well Permit Application 1 f� <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D r V <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 Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> ZgCI A/, W Is C' " ltia w`Iss�, d Asses ors <br /> WELL Location u- Biu C e Crass Street_Saw _c,ly {ace„ Zip q5 2oS Parcel# <br /> PROPERTY L{-Fin LL - <br /> Owner 4,11e e c- Ko--+ Fs4,xk Cc Address Z?Z-;L N Com..�, ./ 4 ,ly Pit oL 0„x Zip 3�Ot+r Phone# 6O L-21b3-(S-Ii.7.S- <br /> C-57Canlraclor rru T l ne _.Address 25-4, P"k AWAD City 1h. 4ne'Y-ZipL7S Lac9ySJJ6S Phone# '72-;-3/3 S`rYGo <br /> Consultant Sub CntrI_I0.r?5 Csny rc,i.,aY• /Address es K arc <br /> J 1_ �e City P xN rx Lrc# Phone#..6c2 - z,�-c+�o,� <br /> GIS Coordinates X37 c 73ZSc1! Y Township 72/V Range jq E Section 3� <br /> WORK TO BE PERFORMED <br /> "EW WELL/BORING SGPT GEOP OSE HYDROPUNCH HAND-AUGER,OTHER•) Q DESTRUCTION (choose type below) <br /> g SOIL BORING#__ 1J j'-L Q OVER-BORE DIAMETER <br /> 11 WELL#__�!W-f y 13 M w,-!N C 1}PRESSURE GROUT <br /> (I'Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPi= CONSTRUCTION SPECIFICATIONS <br /> 4MONITORING Q HOLLOW STEM DIA OF BOREHOLE`_ L Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA —Z <br /> K0EXTRACTION a AIR HAMMERIDRiVEN CASING THICKNESS J IS i TYPE OF CASING 11 STEEL &PVC 0 OTHER <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL ,A.n TREMIE TYPE TO BE USED BAUGERS Q HOSE <br /> Q AIR SPARGEI OZONE XPUSH POINT(GP or42�:JGROUT SEAL PUMPED Q Yes ONo (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 1v='-1/ T 7 L- <br /> a <br /> Q OTHER Q OTHER APPROX BORING DEPTH ?5' S W60LTED TRAFFIC BOX or Q STOVE PIPE <br /> rr FF CONDUCTOR CASING PROPOSED f (if YES/Ifst specifications In comment section) <br /> COMMENTS <ee. `';T71Lt,�.A L,'� G��0.s3r"ctw<i„��”"?,e�.fhS car 1 �`�"` --?a <br /> � <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 /> Signe d x ��--- TiuelCompany AMcrtkz &Z cAL..P? <br /> Prfnt Narrte rG <br /> Date <br /> DEPARTMENT USE ONLY T <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C -701 <br /> WORK PLAN DATED: 2-" 3-of,, <br /> Application Accepted By Oate Issued ror0 <br /> Area <br /> Grout lnspectfon B Data Final Inspection By Date <br /> Destructron Inspection By Date <br /> COMMENTS 1 CONDITIONS <br /> CCOUNTING ONLY AID# FAO# <br /> PE CODES FE=E INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> .U�2 /V1 7-�35 c4xc 3 SR# 00 <br /> C-57 WC -WAIVER-- C-57 Letter of Authorization to stglti perinrt Encroachment dot <br /> EHD 29-02-001 <br /> 6x22/04 <br />