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_ I SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> .. SITE <br /> 600 East Main Street, Stockton, CA 95202-302 ATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.Sulgetip <br /> V=T N <br /> WELL PERMIT APPLICATION I <br /> JUL 2 It [U iU <br /> NON-REFUNDABLE PERMIT EXPIRE$1 YEAR F130M MIE 1@�itE�eONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This y Y " VIdancewith San <br /> 666 Joaquin County Development Title,chapter 9-1116.3 and the Standards of San Joaquin County Environmental Hea epa <br /> Wal Loaation2_A Genfer � cross street t�►la► n- � S t city Sb �a zip Pard#1M00 3 <br /> Property <br /> Owner G e� +Ve" Address x.30.t A) '9LPQr6p1Q_ city S�n�-1�o� zip g5;kALPhone# 3����S�;q <br /> ` C-57 C G T)ril1i Address %°'L OtMec Gr C Zip-IJ 7 T 11c#438 l I 0 Pfwn Ste. <br /> Consultannub Cntr Address kl& 9 !ZS City F*%S o t� r16� <br /> b a Phone�_�_ <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO 13E PERFORMED: <br /> ©NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 89 DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# OVER-BORE DIAMETER. <br /> ❑WELL# APIRESSURE GROUT <br /> [I*OTHER GROUT SPECIFICATIONS QCghtleAtt <br /> ©EXPLOSIVES DETONATING CARD <br /> COMMENTS: t" tAw-l i C56o cel. a c0* t 0-it y-dc ait ftp sL -- _ <br /> TYPE Op WELL INSTALLATION TYPE CONSTRUCTION SP__ECIFICAMON$ <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DLA: <br /> ❑EXTRACTION ❑AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH 18 301 <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> �{ ❑OTHER: ❑OTHER: APPROX.BORING DEPTH [3 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 19 YES,Gat svWfiicatians In commsntsection) <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 nous prepared this application and VW the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Rapulations.and all spplk:abls Cliffornia Laws. - <br /> Signed , l j l Title/Company � cl e.V..64 X15 <br /> Print Name ��• 1N 0 11 Date -I•w? <br /> ef,RARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: D <br /> WORK PLAN DATED: 74 <br /> APPLICATION ACCEPTED BY DATE ISSUED V42Irlm AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> 1 DESTRUCTION INSPECTION BY DATE <br /> F COMMENTWCONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE <br /> ' PERMINVOICE <br /> 3 -5150.00 o ti ISRIP = <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT Ll _ ENCROACHMENT DOC <br /> EHD 29-01 10128!09 WELL PERMIT APP <br /> i + <br /> ^� i <br />