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.... �.. SASS JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton:, CA 95202-3029 MITIGATION <br /> -�-": Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.slgov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> FILE <br /> C <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 /> `:1 1 /r ( � I r,.gin:.• r. ? j }`i V,.ii l4� C w, Assessor's <br /> Well Location - Cross Street =:t( i'`%, City Zip Parcel* <br /> Property :k n a <br /> Owner N` ;'-� Address D41 i�; 7�Iti ' ''k 7 ✓iC � �tZS 1 <br /> City �aGZip Phone# f <br /> C-57 Contractor �Ul:: =` wLl " Address �S✓ r.,v°v�'iu ul f�,� pair» �(GL' <br /> _ City t` Lic# Phone <br /> Consultanti'SubCntr `:Y'+,l Lha Addressjs$. �- A*Ijr^�rCity n- rF i wuM-8. h(i1lE >jc''tit• <br /> ��. Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 4 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# Q OVER-BORE DIAMETER kIr <br /> ❑WELL# I M, PT{W- i D PRESSURE GROUT <br /> ❑"OTHER) GROUT SPECIFICATIONS <br /> COMMENTS: r +l �~ 1p, �- '✓l�!' c nt, - n y. 11n,l11fl MW-I!? MlJ 3, G 4 /Ll[nl-I� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> }' MONITORING Ij HOLLOW STEM DIA.OF BOREHOLE IJI ff" ®MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ++ <br /> ❑EXTRACTiON ❑AIR HAMMER/DRIVEN CASING THICKNESS Qk TYPE OF CASING:❑STEEL ❑i' PVC ❑ CTHER <br /> �• i <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 33 ...__'.5 TREMIE TYPE TO BE USED AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:IN Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 111*4 Y <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH _W X3_ f�f BOLTED TRAFFIC BOX OR E]STOVE PIPE <br /> CONDUCTOR CASING P OPOSEb r� <br /> COMMENTS:MW I'D s,T•-ll � vi' �S' f?-te CdN�4 kl V c.r f,AS;kg (�°`Gl ( YES,list specrrcations in commens section) <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 alf'aPPlicable California Laws. <br /> Signed ��- .,p TitielCompany ��''��� �t'lJ,i^Ch ✓dt�h�H� ��:"},t'L� <br /> Pr'sni Name <br /> Acti, b Sn dh j _Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 32 Z_. lel . C iQ 1 I,�QY nt a S+Y e e_ `j <br /> -ho c,+•4ayl <br /> WORK PLAN DATED: 1J6 y U n r E! e2('( _ _ Y <br /> APPLICATION ACCEPTED BY Fb L . DAT`E�ISSUED D AREA <br /> GROUT INSPECTION BY Y �F 2�`A4 FINAL INSPECTION BY Y )'J7 r DATEZ$ 01 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 1 ! r110 n i+0 r`" WehS <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> X501 $ I, Ot� 89. 061 20330 � n '`I /lo 49 SR#aoSG492 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> EH0 29-01 1115107(WEB) WELL PERMIT APP <br />