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San Joaquin County <br /> Environmental health Department SITE <br /> 600 E. Main Street,Stockton,CA 95202-3029 MITIGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sj�ov.org/chd UNIT [V <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 compliance with San <br /> Joaquin County Development Title,Chapter g-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> EAST SIDE of HwY 33, EASE er� � 9530 f Assessors <br /> WELL Location n)=r RAIr,A'1ON CANAL Cross Street wELTY RoArc ity /CYhaS Zip Parcel# 2555- Z60 - <br /> l(7 <br /> (3oP-ING P869j A4CE55eD VIA VJEz.7 RDAD <br /> PROPERTY <br /> Owner ('IICHAEL� o(SE7TAddress PC)� 80X 2773 Cit VerV)allS Zlp(pp 5.30pp <br /> 9Phone# NA <br /> C-57 Contractor RS1 1)gjLe'1NG Address 22D- N, EAST Cty WDoDck,`� IS77kic# 90233 YhoneI-g-2YZ`/ <br /> Consultant/Sub Cntr5A le Address3goo l4fcL¢f'AVe�Sfe0 ty$gcRAMUXOA NA Phorie#C9f6 l6-3o75 &I <br /> l21 . -�q� 37.10302 ,Townshi 3 _ g (O EAST Section_ 6376 <br /> 55 <br /> GIS Coordinates:X , 7 .Y p Shu Ran e JPQ <br /> WORK TO BE PERFORMED: <br /> `<NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER') p DESTRUCTION (choose type below) <br /> ROIL BORING# SB-2.6 aOVER-BORE. DIAMETER <br /> 0 WELL# O PRESSURE GROUT <br /> 0-Oth� GROUT SPECIFICATIONS <br /> COMMENTS:T� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> U MONITORING U HOLLOW STEM DIA.OF BOREHOLE2-3 v p MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: JVA <br /> Q EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS N A TYPE OF CASING: a STEEL p PVC a OTHER: �JA <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED: []AUGERS XHesE7P1CM/E <br /> U AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: []Yes a No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING U HAND AUGER GROUT SPECIFICATIONS NEAT C5MEP1T <br /> U OTHER: n OTHER APPROX.BORING DEPTH yn r a BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordi ces, RuleReg tions, and all applicable California State Laws. <br /> Signed x M141 Title[Cornpan 1pro e CLe/oSp—C—t'60f $f <br /> PdnLName WlLL�14M SLOGU K Date <br /> DEPARTMENT USE, /ONLY/ <br /> SITE MAP IN UNIT IV FILE ADDRESS: <br /> WORK PLAN DATED: <br /> 1 J J nr <br /> Application Accepted 8y f<'�^^�`l� "'/, Date Issued �� Y Sr �'-% Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: (.C,� f`f� <br /> FE")DUAIFAC# <br /> NT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> wq 1 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> END 29-02-001 web <br /> 622/04 <br />