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1 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:t"rrrN.sigov.orglehd UNIT IV <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- 115.3 nd tpe,Standards ofSanJoaquin County Environmental Health Department. Assessor' <br /> EJWell Location gib`.1 J' � ��� Cross `� City 0 1 ZIP Parcel#�n <br /> Prope �Q L C Zip Phone# •��E? 1 -Zl"1 1 <br /> Owner [��t Address dy <br /> Q 1 �5�, �t2S.3ii 3-tii►Ru¢� <br /> C-57 Contractor Cee' �% 1n Addressy-0 I '� "a city � 1� ZiP `� Lic#4• 1 S Phone <br /> onaultan ub Cntr Address 1 r V City tx�n Lic# Phone kc <br /> l • Z Z� <br /> GIS Coordinates:X Y ownsl�lip Range ec►ion <br /> WORK TO BE PERFORMED: <br /> [:1 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> El*OTHER �,// y�� f3 {, t GROUT SPECIFICATIONS (�A <br /> COMMENTS:Ci.�wL ttf!►1C+ IMO �! rG�-II�QR'� fIft k ! `�'17" <br /> tj 'T <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS Jr <br /> IR <br /> MONITORING 'HOLLOW STEM DIA.OF BOREHOLE 6" ❑MULTIPLE CASINGS C]MULTI-LEVELWELL CASING DIA: <br /> ❑EXTRACTION [IAIR HAMMER/DRIVEN CASING THICKNESScs`4o TYPE OF CASING:❑STEEL KPVC ❑ OTHER <br /> J <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [I SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS lW at Qa�LO <br /> Ir <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH '"N-r °S BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> r CON C`OR Z pWQVOSEO ,Of YE 5,Iia s°` a-lions M comme�f}amino) <br /> COMMENTS: W.�_f ,t�V Y32 C�1P r� �hc�a-'Ik'� Li117X 12 �Q►"P <br /> �t o u bth V1tc It sfti'1- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby that I have spard this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatf and all apps, a to California La <br /> Signed L-A.— IyTitle/Company <br /> fJ tktlb <br /> Print Name � I--uC(C� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY _ FINAL INSPECTION BY _ __—._ DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSIC O NDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITfSERVICE# INVOICE <br /> CODES <br /> SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 115J07 <br />