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SAN .1OAQIJiN COUNTY Is FILE COPY <br /> HEALTH EALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> � <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <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 Co m�yy Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> `1` /V. "A"0eV'(fst 6rtay� Assessors l'?9 bsbS/ <br /> Well Location �(�TS(g rossStreet _----_ City $-Foe��oN Zip �Szn6 Parcel#_2bta.G.� <br /> Property �'l l 1~. Ma2�1. S�t - <br /> Owner Zip— _—__ Address _-- —�-- Clty_�-t act Zip R5 zo2 Phone# <br /> C-57 Contractor TAe✓ Gou s,4kA _fjAddress cmmCity�1 etetAK4P tr oPhone 9100-37L-I bQ U <br /> Consultant/Sub Cntr_—___ —_. Address---_----------_ City _ — Lic#—___Phone—_--____ <br /> GIS Coordinates:X 3o.ocA- -- ,Y ��2--1 '53 Z-- _,Township ___--_---- Range-__._____ Section <br /> WORK TO BE PERFORMED: <br /> 14 NEW WELLIBORING(CP GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING#_ ra'o_tys�'cL1wyLcd17� 3._ ��vt..gS =1t lana El OVER-BORE DIAMETER_—__—_ —_— <br /> I$WELL# El PRESSURE GROUT <br /> ❑`OTHER�/►—'—,1----__-----___._ othll GROUT SPECIFICATIONS <br /> COMMENTS:--!!1 �L� --' ---- � ---- 1 `F -- -- <br /> - -Tn cA. o res <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE ig/� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS—" TYPE OF CASING:❑STEEL 9 PVC ❑ OTHER _— <br /> ❑VAPOR ((MUD ROTARY - - DEPTH OF GROUT SEAL 1_f-O_2"�TREMIE TYPE TO BE USED14 AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)__ GROUT SEAL PUMPED:J4 Yes Ll No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER ___ GROUT SPECIFICATIONS <br /> ❑OTHER: _ ❑OTHER: APPROX.BORING DEPTHjvo _ ❑BOLTEO TRAFFIC BOX OR [I 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 /> Regulations,and all applicable California Laws. p �C.g 2�.aa►,S <br /> Signed —� C--621 <br /> ------ Title/Company <br /> Print Name - ?G -- L= ------ -- —Date---1 j 9 / 0 B—T—__-- <br /> �DEPARTMENT USE ONLY ,� 2—f-.5-0� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: YJ /�/! ---- — !�7----- <br /> WORK PLAN DATED:----- —————————— — e!V�7 <br /> APPLICATION ACCEPTED BY --- ---___-------- DATE ISSUED_ — AREA <br /> INSPECTION BY _ ---__— FINAL INSPECTION B `�'Z <br /> DATE <br /> DESTRUCTION INSPECTION BY______—_ DATE------_n..,,mn�• -----__--_ ----._ <br /> COMMENTSJCONDITIONS: ----------------- ----____----- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERViCE# INVOICE <br /> 29b N�vJ L913G, ?12z sR#b 5taq <br /> C-57_—_WC -----_-WAIVER -----_C57 LVTTER OF AUTHORIZATION TO SIGN PERMIT _ --_ENCR vMQE—N'Tw,DOC — <br /> EH0 29-01 1515107(WEB) WELL PERMIT APP <br />