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( ' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> w.. s <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> a Telephone:(209)468-3454 Fax:(209)468-3433 Web:www-Sj4ov.orc/ehd UNIT N <br /> F <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 andlor 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 /> Well Location SIN �J IbtbA,ti S E Cross street C 4^ys� city 3Dc. "an.. zip I a 2 P rceles#rs o <br /> Property r �-`_C1+L_ r <br /> Owner _ ASO Fi�� Address OyA�• L��Afl�fia City��7iC�4[,[i/ �i Zip. �2+D2 Phona# � q�-8 � <br /> C-57 Contractor r:.t'Address 311 Z ardl-ft -G r Cit�cgr�iw IOrL�KELZip t Lic# 0 Phone <br /> Consultant(Sub Cntr�1ko i S Address kAr,V J SiiL 124' City T61so WL_ Lic# Phonela"9-ts -,zgm <br /> F, GIS Coordinates:X Y Township Range SeCtion <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) CM DESTRUCTION(CHOOSE TYP BELOW) <br /> F. ❑SOIL BORING# COVER-BORE DIAMETER J4 <br /> ❑WELL# PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS Ids <br /> ❑EXPLOSIVES DETONATING CARD <br /> CD� t <br /> COMMENTS: '� l�wwL �_? w 'l 1HI <br /> w� • W- !'I to <br /> Z 4-4W"A i <br /> i ., In <br /> TYPE OF WELL INSTILLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ©MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED[2 AUGERS❑HOSE <br /> E3 AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING ❑BAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (RYES,list spedikaWns In comment seMon) <br /> Fit COMMENTS: <br /> F NOTE: OFFSITE.BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cer ft that t have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a le C a Laws. c i <br /> r Signed .�`+—'_ _ ` T'dlelCompany &y G,% 5 DtL.w&st-( �CADi 5 _ <br /> R Print Name , 8•Js � _ Date <br /> PDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _ZV�[� -S- FILE C <br /> WORK PLAN DATED: -Z-- I b „--- <br /> ;' APPLICATION ACCEPTED BY DATE ISSUED 2$ AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY I {.st.e.�� DATE 10 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> r PE CODES FEE INFO AMT REMITTED CHECKS RECV'D BY DATE PERMn'ISERVICE# INVOICE <br /> 3SDz 460.00 ©yI?T2 -1' 10 SR# S <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT oll ENCROACHMENT DOC <br /> EHD 2"1 1012WO WELL PERMIT APP <br />