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,a DD <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .< SITE <br /> # 600 East Main Street, Stockton, CA 95202-3029 <br /> P 2 1 z�ephone:(209)468-3449 Fax:(209)468-3433 Web:wwv'siaov.org/ehd MITIGATION <br /> UNIT IV <br /> VIRONMENTHEALTH WELL PERMIT APPLICATION <br /> PERMIT/SERVICES <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 Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �'q Assessors <br /> PeollLocation 1605 5• $ Sk. _ -Cross Street E okoc PN_ WCity $}OG�`.�OVI- Zip 520(n Parcel# I(oC11'6001 <br /> a. <br /> owner (4,1-VmAs CT2:cY'p&L 1POK) Address 2015 15- Sli LI-65 Ay1Q,LkI r i t y IV 0 Zip CtS:n Phone# <br /> C-57 Contractor Giml bt-'%\VtftaAddress Q50 IAOWP_ City kQL,4%AM Lic#� 1b Phone(0.25 31.5-5800 <br /> Consultanoilld+ti *gtoni .G Address3�75 tO-5haW 10k City T:Ct16V10 Lic# Phone � ;tqy x1t'2lp50 <br /> GIS Coordinates:X.-30g0 jj%.3 Y 5b55bta3•$ Township Range Section <br /> WgRK TO BE PERFORMED: <br /> 1Ta� IBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') .DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 5 OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: y+w^A&L �—,('neiP_r –VMV C4 <br /> D l ii <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING HOLLOW STEM x Z CSO) DIA.OF BOREHOLE 4` ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 501 TREMIE TYPE TO BE USED[3 AUGERS[3 HOSE <br /> ❑AIR SPARGE/OZONE �❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NO�TTE::MAXIMUM <br /> /FREE-FALL DE/PTH 1S 30') <br /> SOIL BORING )(HAND AUGER GROUT SPECIFICATIONS ��-[!��Gr►rl�Tf [ S !a be14 4&"t Le OK' <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED - (if YES,list apedficaOons in comment sedion) <br /> COMMENTS: 0 O' LY <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENTIIOR 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 /> Regulations,and all,ap licabl California Laws. &60trIOtktc. T{�0316(,`[' 6PEGALIS1 <br /> Signed Title/Company STAN`[ C•, cc)M5ULt,-QQ(a <br /> Print Name vio0 Date 9,/%,a)W09 <br /> DEPARTMENT USE ONLY FILE <br /> C <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 160-3 Iia S �5 [. ■ <br /> WORK PLAN DATED:— I I O <br /> APPLICATION ACCEPTED BY DATE ISSUED Ot 7.Z AREA <br /> GROUT INSPECTION BY Y� LL�nu,�co,,._ FINAL INSPECTION BY �:�� DATE br4o <br /> � <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: C�HAOL b ( ewe/] L CA�1.rnw �.�1rYu t `^06.4 _ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 35v3 �{3`<<nG Z1632,z Z,(ell SR# S 8'3 <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 /> j <br /> Ik �. <br />