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*. SEP <br /> • SAN JOAQUIN COUNTY . <br /> CE V EuENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 1 5 11Thone:(209)468-3449 Fax:(209)468-3433 Web:www.sioov.org/ehd UNIT IV <br /> ENVIRONMENT <br /> [HEALTH WELL PERMIT APPLICATION <br /> PERMIT/SERVICEI�OWREFUNDABLE 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 Location9.57Db S.OUo,.,Tn Cross Street W.Il'�'-'$har CilyTrPlcy Zip�3U1-7500 Parcel# ol%-150-02, <br /> Property MRTS P .,.ld-ei f r' <br /> Owner lvn¢.Ez�{Yea-moi. Tr>_Kr AfldressCity Zip YEA% Phone# <br /> C-57 Contractor Fut,an Cor uLTP,,rs Address M04cl E.Fcolzr= .ce Ave City5aw'A $Iw Lic# j IgPhone(Sred)903-0055 <br /> Consultant/Sub CntrU?,S AddressX70 C-,CdEt...Y 0A"Da. City 5ttwrerrro Lic# Phone9rSo-893-9675 <br /> GIS Coordinates:X ,Y ,Township _ ,�S Range TJ E Section 36 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDRO%U CH,H - THE ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> MSOIL BORING# CAp998 t CP0899,CPCACO PDgy1,CP OsIIO CPo9n ❑OVER-BORE DIAMETER <br /> [IWELL# - PRESSURE GROUTCernent elvaay <br /> <o.f:vlolevt <br /> [I'OTHER 641�Y�S GROUT SPECIFICATIONS <br /> COMMENTS: Lm A-to .� {a to, d-�'t'erintntd <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 )q PUSH POINT(GP O � GROUT SEAL PUMPED:1R]Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> A SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS CeWVA*}Slxmi_ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 100' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list 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 /> 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 Title/Company <br /> Print Name Date <br /> '' <br /> DEPARTMENT USE ONLY t �a/� t <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �S 7 UO C4A,4S Mian, /\6_ " L)OTC err-4'1' 'Lt'-D L <br /> WORK PLAN DATED: CUR W O-c.t P q t� <br /> APPLICATION ACCEPTED BY DATE ISSUED 1� 0t/ AREA '1 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE / w 11' <br /> DESTRUCTION INSPECTION B�Y� � ,/, p.r �� .Q� � DATE T <br /> COMMENTS/CONDITIONS:0&, caLQ. fir" [ ./�u^V'uSt IF) <br /> L <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> ar f I - I - Ol018 yh4iI I 91 JY I SR# 6DA38 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />