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op4`''N.c � SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> X SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> c.. P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.or_g 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 County(Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health cDlepartment. 0- Li 1� � <br /> Well Loca�tio{n� 1�}ao Nil-�)C t `~ ro s trreeet u eJM�Y City �y_`�LL4 Zip 1 o� Parcel#iso} <br /> ty <br /> OwneProper—"_`\ " ` �j� Address��o�J EF(��U City `'�- ✓� Zip R Phone# aq4 <br /> C-57 Contractor Wt"'kLn ;� (�"/�►n,.��(J(k"A�Idress g- kU `'WL CW,,W�City C�`�dC�(�-E-?A.� 1Lic# ��11one�1 Q( `�(.S `}— <br /> Consultant/Sub Cntr T`r�C(11 A0ress 555 Ml7( L7Y`,O A J J ityy Arl FVWrK� `Lic# Phone q(s <br /> GIS Coordinates:X Y ,,Tow r3 �`fll l 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 /> WELL# J MOP.l i(�w-I Citi � ❑PRESSURE GROUT <br /> *OTHER I GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS q:4adidPte­ <br /> �1- <br /> ONITORING HOLLOW STEM DIA.OF BOREHOLE t� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:7- <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Si In• D TYPE OF CASING:❑STEEL aVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL -1 1 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ''❑ T No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [3 SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS A)6 T (^4{'1�/�/V /-7 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3/ 8'BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> n O UCT R CASING ROPOSED (if YES,lis specifications in omment s ction) <br /> COMMENTS: OYN �V XCl g' v <br /> NOTE: OFFSIT BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will b done I ccordance with Sa oaquin County Ordinances,Rules and <br /> Regulations,an applicable California Laws. <br /> Signed Title/Com any 1 S <br /> Print Name D e t O—V <br /> D T US ONL <br /> SITE MAP IN UNIT IV FILE,ADDRESS: b <br /> WORK PLAN DATED: db <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION Y DATE <br /> COMMENTS/CONDITIONS: /y <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMIT CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3sa1 b�6�s �o �Y/OS SR#�SS67 3 <br /> 0 3 goo00 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT i ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) ` WELL PERMIT APP <br /> ,_ o tw4-�a� � M.w-e-11 �"Y'���/...fff���!ll,,,///___vv�ai'...►'..yvv annn/��i��� � . <br />