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.TAN %JUAWU1N %oUUN 1 T <br /> = c ESIRONMENTAL HEALTH DEPAR_&NT <br /> SITE <br /> y r 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> tom; Telephone:(209)468-3449 Fax:(209)468-3433 Aq� Web:www.siaov.oro/ehd 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 DDevelo mLent Sle,c aptar 1115r431nd the Standards of San Joaquin County Env)ronmental Health Department. <br /> Assessors <br /> Well Property <br /> on' k a (�iurcl_ c.�d Cross Street W. I(t� rseet cityTrucY. CA Zip� Parcel#�5a-ISO-01 <br /> Property �pq <br /> Owner At;e a 6,\fl%rikao Address 2551(- S-&A+O.� City h c- Zip S-7Snhone#-Sh B3,-3415 <br /> C-57Contractor6r�r�-Or1ll�� Address 272bta)alwtJt„a Citys'q ( 4,11 LiePhoneRZ5-313-SHOD <br /> A106 <br /> Consultant/Sub Cntr URS Address ZS-lO roa &Mam Oo.Ra"D4-' CItYS-CVC Uk6D Lie# Phone56B-JR5-%,'Ie <br /> GIS Coordinates:X 'y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> RSOIL BORING# A bbn_ 'nom 4009ISl ❑OVER-BORE DIAMETER <br /> WELL# ®PRESSURE GROUTCer.ln..ct A,...w.. <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE 2-" []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 SPARGE/OZONE Id PUSH POINT(GP OR42D GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> IRSOILBORING ❑HAND AUGER GROUT SPECIFICATIONS Gxtn..-.3' SL. . I <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH-t3or ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (Ir YES,psi specl0caeone Ncomment sedl0n) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 all applicable California Laws. <br /> Signed /z"a, , %,c'lt� Title/Company /�ins�c f/� .,,,,er� irr &e_,IWI(Ug�� <br /> I! <br /> Print Name ge Lb i Date 1 /5-10q <br /> /](� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: �!60S "`v I 01-C/ <br /> WORK PLAN DATED: p, 2-6 0e J <br /> APPLICATION ACCEPT Y DATEISSUED ! AREA9' 97 <br /> �A/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMME NTSICON DITI ON S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> d! off' t v L13&? SR# OS6';n <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT/ ENCROACHMENT DOC <br /> EHD 26-01 1115107(WEB) WELL PERMIT APP <br />