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i <br /> Q <br /> Joaquin Count _ <br /> q Y <br /> ��Y San Joa environmental Health Department Iq SITE <br /> 14' i 420NMt Weber Avenue, 3rd Floor, Stockton, CA 95202 �� MITIGATION <br /> (2' TA449 Fax: (209)468-3433 Web: www.sjgov.org/chd <br /> UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� U <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 n-­�1^Qr m rm+ o-111A I�.!the Standards of San Joaquin County Environmental Health Department. 9 <br /> WELL Location /13.��d ross Street 7ltv <br /> �7v 0 Parcel#rsPROPERTY j / �a `Owner c �y�T �✓rW Address�6 // Zip M34. hone#..C-57Contractor / ©� Address /2y r� City rG ip i55,4 tt Phone# M `�I73 <br /> Consultant/SubCntr�/�s',' Address �� J/1��L`City t- Lic# Phone4,)L*� �41/ <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') a DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE, DIAMETER <br /> WELL# /7�J�7 d9! ` D PRESSURE GROUT <br /> 0'Other <br /> COMMENTS: kJ�—�� �C�• r! Gz �c��S e ;IJA-�awll-e <br /> TYPE OF WELL SI STALLATION TYPE CONSTRUCTION SPECIFICATIONS ` <br /> )WONITORING 't}�P-IOLLOW STEM DIA.OF BOREHOLE"0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:r/__ <br /> 0 EXTRACTION D AIR HAMMER DRIVEN CASING THICKNESS l`i v TYPE OF CASING: 0 STEEL )'PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL _ �� TREMIE TYPE TO BE USED: �*UGERS a HOSE <br /> Q AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes Oo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH, 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> �i CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) j <br /> COMMENTS: L_�Z -�_1 I� / / l`--/. <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 /> Signed x Title/Company r <br /> Print Name Date 3/ / - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: IR 0 06 Lam, rr� <br /> WORK PLAN DATED: / /] <br /> Application Accepted By. pate Issued �`� Area V� <br /> Grout Inspection By Dale Final Inspection By Dale <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# R C'D Y DAT PERMIT I SERVICE REQUEST# INVOICE <br /> f CIA SR# 7i <br /> C-57 WC_-WATVER^ C-57 Letter of Authorization to sign permit_ encroachment doc—"f yl1tt!/?il)i. <br /> EHD 29-02.001 <br /> 6/22104 <br />