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foT`•" °; SAN .JOAQUIN COUNTY • <br /> %°. ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> \' 4/ Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sicov.org/ehd UNIT IV <br /> fir r,�y,tki — <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 ille,chappter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br /> 70/ EtI eb r04�, Assessor's <br /> Well Location Cross Street 61.Ie.5+ blp`a.r Ave. City �J LkiVr% zip 95 z0�j Parcel# I57-260-16 <br /> Property <br /> Ownerfs 1�acic�en T Address q;�J City Zip 16;4 2—Phone# <br /> C-57Contractor URW br-,Ili L4�..twa. Address P.O. t X 170 n9City Ishi Lic# T20904 Phone (7 )361-9600 <br /> Consultant/Sub CntrU/) llsc k.6 l i Assc Address3Z91 Rfac Alq City Wisf Saw fi LIc# Phone(fY/0172'W 3'/ <br /> ' GIS Coordinates:X Y ,Township Range Section <br /> 'f <br /> RKkELUB <br /> E PERFORMED: ,,,���rrr <br /> IYI NEORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ��/�\\\\ OILBORING# OVER-BORE DIAMETER <br /> ELL# PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: re t o 1, 1•n 25ft �aror..:t "IM IArk mol { ,d 6 4---kk f-Lm s~I Iy. ('5Roo55gb2) - <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE _ ❑MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> ' ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:D STEEL D PVC D OTHER <br /> ❑VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED D AUGERS❑HOSE <br /> D AIR SPARGE/OZONELy PUSH POINT 8 CPT) GROUT SEAL PUMPED:D Yes D No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> I SOIL BORING DHAND AUGER GROUT SPECIFICATIONS C(4iyy�,-0/yC�/j�— <br /> El OTHER: 11 OTHER: APPROX.BORING DEPTH z7 �-1' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment SmIlon) <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 /> Regulatlon II applicabl a forni Laws. <br /> Signed / n e�� Title/Company 5r.SiF <br /> ' <br /> PrintName Ni 4 K,,yj--gasDate 3I0c1 <br /> ' DEPARTMENT USE ONLY J SITE MAP IN UNIT IV FILE,ADDRESS: `15 W F�-YJ f—T�- <br /> WORK PLAN DATED' 3�'.`vt�OO <br /> ' APPLICATION ACCEPTED BY I ' 1• DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> ' DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ' ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMT REMITTEDCHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> a0l0 6 �ift 4 � 1� I --m;4- a ?a sR# 68 3 <br /> ' C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/507(WEB) WELL PERMIT APP <br /> 1 <br />