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..n Joaquin County <br /> Environmental Health Department SITE <br /> 6.0- r._ AW E. Main Street, Stockton,CA 95202-3029 MITIGATION <br /> a �T4J9 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> 0 `' oWell Permit Application <br /> VJ CSI, l :1 2 �J8 <br /> u `I�IOTfUUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> application is hereb for a permit to construct and/or install the work described. This application Is made in compliance with San <br /> Joaquin County Deve o .3 and the Standards of San Joaquin County Environmental Health Department. <br /> +.a � 1��" � SAN To A Q V I N Assessors <br /> WELL Location 217 f, W E t�_E Iz_ AVE, Cross Street 5t R E E T city S TO C k ro N zip-25gal Parcel# 149 t b 0 01 <br /> PROPERTY 1:0VNTY OF SAN 7oAQVIN <br /> Owner FAG, Mfr MI, D J PT, ddress 1121 E.5C0Tt$ AVS, city 5T0CIhf0I{ Zip_J3105 Phone# 12091 168 ' 9162 <br /> yC•57Contractor ALL Address38091ttElISAN IfAtIE CItyP1At, RVIII 12Ip9566TL1c#jjj3T9Phone#�S00)140-13SS' <br /> I:A W5 <br /> Consultant I Sub CntrtMVINON M99TA L. I IJC. Address 6 5 5. City. RE 14 0 Lic#P6 5'8 S 6 Phone#1916) 01-5.0 3 <br /> 6-0 GIS Coordinates*X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> a NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) I DESTRUCTION (choosetae below) <br /> 60 a SOIL BORING# OVER-BORE. DIAMETER $— i N c H <br /> a WELL# PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: "r`t"'""n H 0 MON IT o k 1 N G- Wt CIS --- <br /> u <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ft <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE,,,, a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 <br /> EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSL `} <br /> SGO TYPE OF CASING: a STEEL I PVC a OTHER: <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEAL Z- I I TREMIE TYPE TO BE USED: I AUGERS a HOSE <br /> a AIR SPARGEI OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS T EM NT <br /> ar 0 <br /> OTHER:_0 OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N A (if YES,list specifications in comment section) <br /> COMMENTS: DtStRVG ION C ITIJRING VYELI, <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 x <br /> Title/Gompany RESIp�1tiT 1tA 1'IRF6 Vf(toi'{!'IEPITAL IN14 <br /> `r Print Name t}S 1p N R A M A G•E Date 10 2 2 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 E ae A y <br /> WORK PLAN DATED: Se <br /> Application Accepted By <br /> Of Date Issued /0 -2�}–D 8 -Area 14 <br /> u Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> y ACCOUqj <br /> AID# FAC# <br /> PE CODFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT I SERVICE REQUEST3SozO 375. DO 2406 �f'lyl io�s4 oa SR# 06S-y3 0300 <br /> C-57— W(_-WAIVER C-57 Letter of Authorization to Sign permit_-Encroachment doc— <br /> EHD 29-02-01)1 web <br /> 5/22104 <br /> V <br />