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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.org/ehd UNIT IV M WELL PERMIT APPLICATION �� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicali o 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 Developpmentt-nttlee,,chapter 9-116115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Loc atl n ..(1 -- ( Cross Street V s o. G Y/[ Cil � � ZI 9 30 Assessor's <br /> / Y 4.p P Parcell: 191-556-0q <br /> Owner_ _ Address / 1R. City Zip lLIPJ,Zip95336 Phone 11 4aS) <br /> C-57 Contractor �.W — Address P-o• Go, 970 city <br /> Lo' Lic«7A09o4 Phone(A00369-96 <br /> Consultant/Sub Cntr E,v6Ea Ssn C. Address 590 N. Wilma /dale City RCPon Lic:_N/A—Phone L.9) 835-66/o <br /> GIS Coordinates:X Y ,Township Range Section <br /> �a�37.8o4 Lon. -IRI. 310 <br /> WORK TO BE PERFORMED: <br /> IM NEW WELL/BORING(CPT,GEOPROSE.HYOROPUNCH,HAND-AUGER.OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®VVELLP rnw on_27 tPlucme.,} aG mwM-le) C1 PRESSURE GROUT <br /> 0-OTHER // GROUT SPECIFICATIONS <br /> COMMENTS: $ eY j C d- Jrs til b P bl'staJ tArfl `M1 ) 4--w rr, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> (MONITORING AHOLLOWSTEM CIA OF BOREHOLE 10-'111 0 MULTIPLE CAS INES El MULTI-LEVEL WELL CASING DIA P <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS 54,, 4o TYPE OF CASING:D STEEL K PVC 0 OTHER <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL to TREMIE TYPE TO BE USED r9 AUGERS 0 HOSE <br /> O AIR SPARGE1OZCNE [3 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:D Ycs C6 N. i NOTE:MAXIMUM FREE-FALL DEPTH 1530') <br /> D SO'L BORING 0HAND AUGER GROUT SPECIFICATIONS Ned), Ce�vy <br /> 0 OTHER:- 0 OTHER: APPROX.BORING OEPTH ;tUi F. n 19 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d YE3.,ul spePficalions HCammvnlstttlon) <br /> COMMENTS: (� �� I urI! CaY slv t1 4 0 61'aF 1 n r plak ite{ 1 <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 aaaI1 appp:c a lifornia Laws. <br /> Signed ')/{ Title/Company (renleJs 4ZSN4fao <br /> Print Name �� ar_ C.r-aW koro( i P. G. Date `I/16009 <br /> (� DEPARTMENT USE ONLY )p r <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> A /•`+ �66 / "// 6 5 -W <br /> WORK PLAN DATED: `/'r'c^�' - �V ro"� '4 / <br /> APPLICATION ACCEPTED BY DAT SUE 6'o AREA O _ q <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATED/ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID FACS <br /> PE CODES FEE INFO AMT REMITTED CHECKR RECV'G BY DATE PERM1IIT/SERVICEM INVOICE <br /> L t ps g -Ib o R#D <br /> C-57 VWC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EH0 39-01 :115'09(VIE0) WELL PERW APP <br />