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l SAN JOAQUIN COUNTY <br /> 2 ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> K <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 4• Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sjgov.ora/ehd UNIT IV <br /> 17— <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- 11 3 and the Standards of San Joaquin County Environmental Health Department. t-S t• �Ov"O <br /> y C (�" ++ h�j�rr Assessor' <br /> Well Location '�14t� •�111i ) �� treet 1,6 ti Wil City 1`U�Zip Parcel# S <br /> Property �+ <br /> owner LOL-wr�oi'1Ef i ILO Address '��`ba�tt1, IU�UI{¢r iCity /S/fbck hII!j Zip Phone# �`� <br /> C-57 Contractor GrtalDr.(�11 Address'150 [kcli" CityJUalf,nL� Zips Lic# �� Phos 2S <br /> yy AA ��{{ X1'3 <br /> Consultan ubCntr�W.2Al Ail I. Addressisq e-wr I� Ay 71f t06Clty _ Lic# Phone 6110--2511-24 <br /> AA e4 I <br /> GIS Coordinates:X Y Township Range i�`Sdct'io�e�O <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GFOPROBF.HYDROPUNCH.HAND-ANGER,OTHER*) DESTRUCTION(CHOOSE TYPE AFLOV1t) <br /> ❑SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS {� <br /> COMMENTS. 1 1�I/I �rC . �L M VCe riw!* I f��0 r O( 2e J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,, <br /> ❑MONITORING HOLLOW STEM DIA OF BOREHOLE �v 0MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA-2 <br /> [IEXTRACTION C]AIR HAMMER/DRIVEN CASING THICKNE4A 'N TYPE OF CASING:❑STEEL PVC ❑ OTHER <br /> 14 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL s?�* TREMIE TYPE TO BE USED (AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ANo (NOTE:MAXIMUM FREE ') <br /> E--FALL DEPTH IS 30 <br /> [I SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS f ���l <br /> ❑OTHER: _ ®fjyTHER: APPROX.BORING DEPTH I ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 I NDUCjiZ CASING PROPOS O (;VEjt'iiyspec�yalons ince IsaUbn) <br /> COMMENTS:tQ "61 lAF >' fR-S 31"i • kTP_U Z Yi•' LSV r,t t t lI -Ik lo' <br /> JY7 i C.0 L11P ' s <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby,�fy that I ha a prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation ,and all apf�lr abih California Yaws. <br /> (/ fV,(/ r <br /> SiDned Title/Company O <br /> Print Name ' Qty V C r Date "2"3"�� <br /> 71 DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _7$<`� T IPR� SI T <br /> WORK PLAN DATED: 00 t7V lL V"4 <br /> APPLICATION ACCEPTED BY r• DATE ISSUED O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY* AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> zq o� (00. �J „•„� NL- o z SR#5 b <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2301 1115107 'HELL PERMIT APP <br />