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SAN JOAQUIN COUNTY <br /> b, ,ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> .4- <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.si.gov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to Safi Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County DevelopmentTitle,ch7,4,r—. <br /> ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> -7,01 W Uye.h 7,4�. Assessor's <br /> Well Location Ifs yern..r,' Cross Street IAks+ WPAoc Ave, City 54wckfy^ zip %103 Parcel# 1$7-260-16 <br /> Property r <br /> Owner sT _j--`}bpp�yc -6^, Address 't 2. N G. ( d�Of A� City G Zip !F yPhone# <br /> C-57 Contractor V? W Ur�(fix.c tt. Address �.d. Dolt 170 City (��i Lic# 12d90q phone (20�!)364-1boo <br /> T A <br /> Consultant/Sub CntrUJ II4.,, - J/.,�1i Af;lk. Address 3ZI;j Gaca,ti jyl City 14A 5a4tw4,,aA Lic# Phone&0 372-8 3J/ <br /> GIS Coordinates:X Y Township Range Section <br /> TRK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# DP-'. OVER-BORE DIAMETER <br /> WELL# PRESSURE GROUT Ne a} 4AAV%4r�t <br /> [:]*OTHER ` GROUT SPECIFICATIONS <br /> COMMENTS:NI . t 9"V, idorkred-,Qh <br /> It, 4,4. t'e,'4,y 1 Ms (�R005511�2) <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> f IN <br /> ❑AIR SPARGE/OZONECPUSH POINT MAOR CPT) GROUT SEAL PUMPED:❑Yes [INo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ElHAND AUGER GROUT SPECIFICATIONS Cr2Nrrri <br /> El OTHER: El OTHER: APPROX.BORING DEPTH �5 t-}' ❑BOLTED TRAFFIC BOX OR ❑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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation all applicabl a'forni Laws. <br /> Signed � � �-- Title/Company �I'. `•4Tt01 r <br /> Print Name Nic-Ic S Date- kn <br /> DEPARTMENT USE ONLYf <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 726 I W �-Q�, c"_-4V <br /> WORK PLAN DATED- 31 g 1 O9 e <br /> APPLICATION ACCEPTED BY DATE ISSUED 3140 lb�nAREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CONDITIONS- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> lQ'-S —M� a -23 SR#�'L?, <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />