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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE =� 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.s'gov.org/ehd MITIGATION IV roa 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. /�O L�n s /� L ��/ / - ,Q /_. Assessor's Well Location IG 7 Cross Street )r 57 7' <N�CGi City 'r�1 Zip ✓�I Parcel# Property /�/� / r / r� Owner%fjTfW.5 S-" tf Address 'z�7/S�SGic'/ S Q /GYJCity C-fiC�1.10 Zip931Z6 P h o n e# 55�2�/3-n/-/ C-57Contractor Gv� �r►��L4 Address lloJe d City �iLte-Z L i c#Yk5165-Phone ,9Z67 343-SF-M Consultant/Sub Cntr l, •�e.v { . V��! Oress / �O (� 1 City 1`�^G Z,P ! 7?Y2 Phone 9/6-95 -91/2' '� GIS Coordinates:X /2/. 25>Z1/- Y 3y 9%0990 Township 7"if'WI/ Range R 6 7'F Section 3?-1.36 WORK TO BE PERFORMED: Ca w�oc7 I�e= LoS Geste°S jkj NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ❑OVER-BORE DIAMETER ,)WELL# /g./9_ ❑PRESSURE GROUT [:1*OTHER GROUT SPECIFICATIONS COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING OHOLLOW STEM DIA.OF BOREHOLE g"' (( ❑3 MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: 2~ ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 5"L 4 TYPE OF CASING:❑STEEL j9PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDkAUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes C1 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Al,?eyy��lEii/L� 3 s/v �✓+d�' i ❑OTHER: ❑OTHER: APPROX.BORING DEPTH _� BOLTED TRAFFIC BOX OR ❑STOVE PIPE C NDUCTOR CASING OPOSED it YES,lists ecificalio in comm COMMENTS: tVt S (60 LhA te'(/ NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and all ap Icable alifornia Laws. p, Signed Title/Company 1 uK)(�' "moi /c�� s�� s &C Print Name Ih sTeiJP�44SCd1/� Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 1A0,Y IZ S A- a� WORK PLAN DATED: APPLICATION ACCEPTED BY 0, DATE ISSUED , - 2Z D AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE 4-05 DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE 00 06.5r325- Gee SR# 5_79912r' C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _tit_ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 11/5/07(WEB)