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e Ut" e • SAN JOAQUIN COUNTY . <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.siaov.ong/ehd <br /> UNIT Iy <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 Department. <br /> Assessor's <br /> Well LocatiPropertySlon I, t Cross Street W. IttbG�r,=* / City TrAcaf [fit _Zp�� Parcel# J5-64-10-pi <br /> Owner--p�P �Grt+1 ty Address �)6�E 61110<R-�I,�(,t<u.�� City_ (r f Zip Phone# <br /> C-57 Contractor Graga J>- ltT tT Address 2726 Wa1„i3Avx. City$,4MI tall Lic# -t65-Phone9ZS-3t3-$Stab <br /> yteIto <br /> Consultant/Sub Cntr UW5 Address 2b2O fonkewo..q 07 Ls 02 CItyI-i'cvi .m Lic# PhoneS:50-18R3-li <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> JK NEW WELL/BORING(C-T,GEOPR^AE, Y U C AND-AUGER,OTHER-) [3 DESTRUCTION(CHOOSE TYPE BELOW) <br /> lI$t SOIL BORING# I J TQC §�rP 3 6or rls S&fA jam] ElOVER-BOREDIAMETER <br /> WELL# B PRESSURE GROUTCemA.,d-511, rf <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 HAMMER/DRIVEN 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 19 PUSH POINT(GP ORS_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> J&SOILBORING ❑HAND AUGER GROUT SPECIFICATIONS Ccwy-4,ct Sl u.w.t <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH`t30r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES•list spedffm ions in comment section) <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 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 <br /> /z"cu- 7 13t TitlelCompany <br /> Print Name 44ELb( Date 115-/oq <br /> p QDEPARTMENT USE ONLY �r <br /> SITE MAP IN UNIT IV FILE, DRESS:: J Slob Liyl�1 mB 4 <br /> WORK PLAN DATED: -/'�I /0 )� <br /> APPLICATION ACCEPTE ' I /�' A(�- — DATE ISSUED /[t4 7 AREA <br /> GROUT INSPECTION BYI1 FINAL INSPECTION BY DATE ? d� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE I PERMITISERVICE# I INVOICE <br /> Dl 1 RrJ- �?` a l D I b 1 Ll-L -Lio <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2901 1115007(WEa) WELL PERMIT APP <br />