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DP4 I"' SAN JOAQUIN COUNTY <br /> D <br /> HEALTH EALTH EPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.orolehd <br /> <rFQR1N UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct anc.9r install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,chapter <br /> 9.1115.3 and the Standards of San:,cy-•:.CoT.nty Environmental Health Department. <br /> Well Location V05.A& //sf.W reset L°l «t tvd' Cit l� + ZI 3`3 Assessors <br /> 114 „ E R � y p K Parcel#_ t om ` 1 L i•. ( <br /> Property _ <br /> Owner .`Itr %q t:r-c.k e" Address .I'l. 0p �LC -./_I�-I�-'Y'i•1�: City-__� �_ ZiP 95- Phone <br /> C•57 Contractor V i 10.bb)11� Address 3Oo6 MA AAILIQ& City Sbc_k4a, _ ZiPTjS 9_Lic it?].t0j Qy_Phorl��l1Gq-14 <br /> ConsultanVSub Cntr C, ^A iidt Address? A'1,.tcsi;,S'j$,/k 4T.' City v-•e..vy,,,xc Lic# -"'"' Phonei`(ii, �'fi -cr iK'�3 1 <br /> 619 Coordinates.X j t�r . F ,Y L1« - =i=t -Z 1•r Township C-")Range� Sectiun <br /> WORK TO BE PERFORMED: J <br /> ❑NEW WELL/BORING(CPT,GEOPROHE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> (3 SOIL BORING# ❑OVER-BORE DIAMETER <br /> L]WELL# t ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS I 4 , ,r c. ..... Al h�". >:�t It(K'..f.�� ', 'o cf <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ..t� 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESSo4-Ef JL TYPE OF CASING ❑STEEL (it PVC 0 OTHER <br /> ❑VAPOR 14 MUD ROTARY DEPTH OF GROUT SEAL 3`s TREMIE TYPE TO BE USED&A AUGERS❑HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPTi_GROUT SEAL PUMPED @ Yos 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 9 SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS _ <br /> 0 OTHER. O OTHER'. APPROX,BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (ii VES.fist ap kaboni in comnont wo,ont <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances.Rules and <br /> Regulation end -ppacabie California Laws. <br /> Signed __Title/Company �i+Z0, <br /> Prins Name , V.6�r:i -i ,.= 3..� Date <br /> Dp <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: O 0 �S CUt.C/d') , /} 721-" 41 C, <br /> WORK PLAN DATED: d 7-7'// 2y,0�0 ���� �� <br /> APPLICATION ACCEPTED BY aikzll'�Ci DATE ISSUED AREA �'i 5 9 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE It INVOICE <br /> 90! S' cc 9 69 14 /y i3 o SR#,065r6 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2401 10128!09 WELL PERMIT APP <br />