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AQUItY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ( <br /> Telephone: 209 468-3454 Fax: 209 468-3433 Web:www.sigov.ord/t=hd <br /> ac;fioa`P p ( ? ( ) UNIT IV <br /> WELL PERMIT APPLICATION <br /> LEON-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 /> 4 l h��� 1 �+•�w, Assessor's <br /> Well Location i ay A A. 1 Sk Crass Street E t upm_A� City . O,r Zip ✓+w 2 Parcel# 000 1 <br /> Proper` <br /> C- r r�11Owner 6rr\.1 0,.- Address -fo-4 K rc/ <br /> 54- . .<-nA Flay City 0-�.tt50-Yo� w ip��Phone# <br /> C-57 Contractor !� D(AiylC L? Address 3(p3G2 omec C$r City ►YiGi�O Cttt�Cv Zip -_Lic# ��td PhonekW. <br /> Consultant/Sub Cntr Addresem G iron ilk ?- 1ZS Cit rr llb,98$. <br /> City Yt7 50 wL Lic# Phone-1- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# OVER-BORE DIAMETER <br /> ❑ <br /> WELL# PRESSURE GROUT <br /> El*OTHER GROUTSPECIFICATIONSrttQ,� ctrvte <br /> 1 55 <br /> [:1 EXPLOSIVES DETONATING CARD <br /> COMMENTS_MW-I3M �AW-t,P prt5SQ1( : FIrO%rt it- tc <br /> O whP11k "kbD 5 t;ea <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN 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 IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,fist 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 /> ]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 /> & <br /> Regulations,and all applicable Calif o 1a Laws. e <br /> Signed �- r L� Title/Company go V S eel pi t-qi S <br /> Print Name � .�� WOttj Date <br /> DEPARTMENT USE ONLY —At copy <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �b S <br /> WORK PLAN DATED: 2 <br /> APPLICATION ACCEPTED BY to DATE ISSUED AREA <br /> GROUT INSPECTION BY ��lM.l.Ge/� FINAL INSPECTION BY LA"A DATE 1D jCJ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3 S t�z I by,vo C)Lf I Z,S-2 CX_ M V to SR# &0& 6 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT /ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />