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_ SAN jC)AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SfTE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION x . ' Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT !V WELL PERMIT APPLICATION --- - NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 17 ' 5.1A r ali ,q Assessor's - Well Location'3 Cross Street - «� u Cit r_ 10C�-4 Gt'1 zip 952 t ? Parcel# Prope Owner ,ct,C Address, f!?; �j. A,rp<,r l' c,,I City , +QC Kh�_ ZiP 70fo Phone# G�{-C( -133,x`1 C-57Contractor c"� ✓< �,'��°a Address R5Q Howe �O'A:} City A1lekv4i`ie7 Lic# Phone 313--�1�FOO Cons U ltant/SUb Cntr Al} 00S Address rn;i;'A Dti(A_ Gity 0,t"e'e t_ic# Phone-t�7-_�J GIS Coordinates:X __..._..... Y Township _, --1 --_ Range--_ 2 Section WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') &DESTRUCTION(CHOOSE TYPE BELOW) (]SOIL BORING# __ OVER-BORE DIAMETER El WELL# --..__._. _._ PRESSURE GROUT — ❑*OTHER _ __- GROUT SPECIFICATIONS COMMENTS: TYPE OF WELL ONSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1) MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS E7 MULTI-LEVEL WELL CASING DIA:__ _ ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS- TYPE OF CASING:❑STEEL PVC ❑ OTHER + ❑VAPOR ❑MUD ROTARY,__ ._...-__ DEPTH OF GROUT SEAL—_rTREMIE TYPE TO BE USED❑AUGERS❑HOSE El AIR SPARGE/OZONE El PUSH POINT(GP OR CPT).'_.___'_ GROUT SEAL PUMPED' Yes ❑No (NOTE:MAXIMUM((FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER _ GROUT SPECIFICATIONS _„ atMvs ❑OTHER: D OTHER: APPROX.BORING DEPTH O BOLTED TRAFFIC BOX OR STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list spesifiCateons in comment hat) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepa tfd this application and that the work will be clone I accordance with San Joaquin County Ordinances,Rules and Regulations,a a licabl rnia Laws. il Signed J rr -- --- -- _/^Title/Company Print Name — j' ._. .�_ f -r -- t �_. = Date---...T - --- DEPARTMENT i ISE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 3`l 3 Z S- A Y- t2 r+� -5-6 I WORK PLAN DATED: APPLICATION ACCEPTED BY !/��ky — G�✓ - _ DATE ISSUED _.f.Tl-f2�r'� _ AREA C C GROUT INSPECTION BY FINAL INSPECTION BY_ _ DATE DESTRUCTION INSPECTION BYa�1 y DATE COMMENTS/CONDITIONS: OL ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE SR# V tcc>� - C-57 WC -WAIVER C57 LETTER OF AUTHORI ATiON'i0 SIGN P NtIT ENCROACHMENT DOC EHD 29-01 1115107(WEB) WELL PERMIT APP