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SAN JOAQUIN COUNTY <br /> cNVIRONMENTAL HEALTH DEPARTMENT <br /> Y 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:wwvv siaov omlohd <br /> MITIGATION <br /> WELL PERMIT APPLICATION UNIT BV <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--I 1 t-�,3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location 1 fCl` J {,L }r� . .)(� ' OO <br /> -P <br /> t <br /> Prop ertssStreet 1`tzS t N:�c: City t��_ Assessor'$,��l� <br /> Zip Parcel#�[`��- f . <br /> Owner "_j�v`� (��, Address ��`�Gt { O <br /> G v ( 1V�tJIIi� ' 11`1(city � Cic <br /> C-57 Contractor CaY'�^l -----'7t- Z'P 7 Phone �-} -f I _ j <br /> N.(� e.- Address <br /> Csa §ub Cntr c ;I � City <br /> I C• <br /> rfl Zip' Lic r{ !' kl Addresst } tE� Phone <br /> h�D-`+�a—(e70 <br /> GIS Coordinates:X city oo �,. Lic Phone 71Y 2 <br /> 3 <br /> f }5C1 <br /> c <br /> Township <br /> WORK TO BE PERFORMED: Range {�S�ction C` ` 411Ej t <br /> NEW WELU13ORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER.OTHER') <br /> ❑SOIL BORING# DESTRUCTION(CHOOSE TYPE BSLOvv) <br /> ❑WELL# 5OVER-BORE DIAMETER <br /> 13`OTHER {G >t'Ti4 C'�- ���X ❑PRESSURrE GROUT <br /> COMMENTS: irR ', GROUT SPECIFICAT <br /> IONS ----- <br /> - <br /> 64 <br /> TYPE OF WELL INS2 '-C) <br /> -- TALLATION TYPE CONSTRUCTION SPECIFICATIONS 'K? <br /> ❑MONITORING (HOLLOW STEM <br /> DIA.OF BOREHOLE <br /> ❑EXTRACTION � L-3_ ❑MULTIPLE CASINGS MULTI-Le VEL WELL CASING DIA: .Z" <br /> ❑AIR HAMMERlDRIVEN �{`� <br /> CASING THICKNESE�144 40 TYPE OF CASING: r <br /> VAPOR ❑STEEL kPV„ ❑ OTHER <br /> l"+ ❑MUD ROTARY DEPTH OF GROUT SEAL _ ��- <br /> ❑AIR SPARGE/OZONE ❑PUSH -- TREMIE TYPE TO BE USED AUGERS❑HOSE <br /> POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes 'No (NOTE:MAXIMUM FREE-FALL DEPTH <br /> ❑SOIL BORING ❑HAND AUGER ' <br /> -- GROUT SPECIFICATIONS ��s'G IS 30') <br /> ❑OTHER; (j tj� <br /> ETHER: i <br /> —� APPROX.BORING DEPTH I, <br /> COMMENTS:LQ _101 Iw��X 1 t ..` 1ylDUCJOOR CASING PROPOS D„ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> +�`. 1�'\ t :.C� "'..r-_ �'b.�•r^.;�i• .".tl . — ��xC"(.Y .,broecifrMimsin= enf sectiJn) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS �2CREEMENTOR ENCROACHMENT <br /> IIHMf r.^ C<� �� .t <br /> TENT PERMITS <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I haye prepared this apytication and that the work will be done I accordance with San Joaquin County Ordinances,Rules an <br /> Regufatlons,and all a ph ably Califorgla P'aws- <br /> �(` 'i p/j !V d <br /> Signed i � <br /> Print Name ' t9yt11 t i` Title/Company ?.iklo" S �? �2 ` � <br /> t Date C" 't <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 0%1 fM+�,� � ?iJc7� aD � E Y7r 7PF}�4r S� <br /> APPLICATION ACCEPTED BY <br /> r <br /> GROUT INSPECTION BY DATE ISSUED o AREA -5(_L-1 <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY <br /> DATE <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: I AID <br /> PE CODES EEE INFO FAC# <br /> AMT REMITTED CHECK# <br /> RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 0,00 IAL <br /> C-s7 WC fl ` o ti � SR#-- <br /> 6 <br /> -WAIVER C57 LETTER OF AUTFIORIZITION TO SIGN PERMIT <br /> EHD29-01 111SM7 ENCROACHMENT DOC <br /> WELL PERMIT APP <br />