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(=PR -16-2:1037 03:3eP FROM: ENPROB 15:S0585225O F'. _ <br />FILE COPY <br />San Joaquin County <br />Environmental Health Departroeni-a ��`�! SITE <br />u ' Stockton, CA 95 <br />304 Enst Weber Avenue, 3rd Floor, 16'_��'� M� lGATION <br />(209) 468-3449 Fax: (209) 469-3433 Weh: %k,xv%v.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />� ''lila�jl'')f'yry�P,f i if1.1.1L1 I� <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS9t�I3 <br />Application Is nareby made to San Joaquin County for a permit to construct and/or Install the work described. This applicdUan 16 rkeda In compllanre wllh San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joeon County Frnironmantal Healln Department. <br />AS 6 B Bbo rS (l <br />�v>iLL Location �Q(Q -t J�}dam l� i�K� Cross Street 1 a City croc-lgroo Z(p S.0& Parcelf � Oo <br />PROPE <br />Cwner_ ZTY / — <br />Cwnar Chit F 11%fnidvrti( Gkh1'�t Addrasa 1 d �OzO MdYt�t�/' t3(ye� C"y t� zlp_15455 Phone* G 361 <br />IREC•57 CanIractor�L( 10,Aa Address P-0 SOY 66 q 3 CHy O&Voj G Zip r G LIQ 90b Phone* s3o9?Y 20 i <br />onsultan Sub Cntr 1AV1 f4 4., Irle . Address ?YgYM-,�Strr 416P C1tyFAlt OtlL<j_Llc;# Phone# YE6 B6313ZG <br />GIS Goo dlnetes: X , Y , Township Ranoe Sed107 <br />WORK TOpg P_EREQRMEO: <br />p NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') D DESTRUCTION (choose type below) <br />KS01L BCRING CS(jl GSQZt �3/�G (, IQ� Z� ��L3 0 OVER -BORE, DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 'Other GROUT SPECIFICATIONS <br />�- <br />C C M M £NTS : <br />TYPE OF W" INSiIALLATION TYPE CQNSTRUCTIS?N SPECIFICATIONS <br />D MONITCRING p HOLLOW STEM CA, OF 8CREHCLE__&f a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA'. <br />0 EXTRACTION 0 AIR HAMMERIORIVEN CASING THICKNESS AJA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER - <br />0 VAPC9 0 MUD ROTARY DEPTH OF GROUT SEAL Fu Lf TREMIE TYPE TO BE USED: D AUGERS RHOSE <br />0 AIR SPARGE/ OZONE )rPUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yee )KNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />XSOIL BORIN* 0 HAND AUGER GROUT SPECIFICATIONS AJG,%r -Olt"v l— & l • L,�wroa; re. <br />0 OTHER: tl OTHER APPROX, BORING DEPTH 5'- ( Ir r D BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED NO (11 YES. list specificatioms In comment sactlon) <br />COMMENTS <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that ,/slavepre red thls application and that the work will be done In accordance with San Joaquin <br />County Ordinanc , ules a Ulations, and all applicable California State Laws. <br />Slgnod x .�� r T1;IelCompany <br />A)A/ 4E �L-- L 124620 Q <br />Pdni Name 0T 1 Data �� 1 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED:_ - ___1_ <br />Appllcatlon Accepted By <br />Groul Inspectlon <br />!O s• <br />ZT' Area 66 <br />al Inspaction By Dete <br />newu-'Iun Inspection By Date _ <br />COMMENTS I CONDITIONS; <br />ACCOUNTING ONLY: AID* <br />FAQ <br />PE CODES <br />FEE INFO AMOUNT REMITTED CHECK <br />RECD BY <br />DATE <br />PERNT I SERVICE REQUEST t WVOICE <br />C-57 WC✓WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc41111 <br />CIID:9-03•Col <br />6!::I(4 <br />