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AlSANJOAQUIN COUNTY aa <br /> ONMENTAL HEALTH DEPARTAT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNIT 1V <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES t 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�Tiitle,chapter 99--1115.3 and the Standards Of San Joaquin County Environments!Health Department. <br /> Well Location Z,5- E( bia,"dm Crosy Street !W,* 7 yL' �-. Cit �"I-4c-ICt p / Assessor'8 I <br /> Propetly �1 " �` �/ A Jes cry L.�. Y r a+.. Zip? <br /> Parcel <br /> Owner_ a-f'oc:ia-t'4K 1'4U 3 r n-� Address 7-014t'�,A�Ik4�-t "6�t7�(t .�,,.y�uiri� `/ o t� <br /> C —a / I✓c+sr(- 5fi. <br /> Phone <br /> C-57 Contractor — 10r' Address <br /> Consultant/Sub CnU 0 GG6J Fa4 ,Address A City ` �4l ! Zip S7 pUc# 6#Z�Y p3,y7LPhone <br /> Ay, <br /> f , 4 <br /> tl 7 <br /> Cicty � 4 1{Lic# f Phonead?:r f' l�qOc"�C7 <br /> GIS Coordinates:X 121.7Z Z'� Y m ulf(O K 9 ,Township J J Range L 11th Section <br /> WojRK-TO BE PERFORMED: r r°>< <br /> EW AORING(CPT.GEOPROBE,HYprPUNCH,HAND AUGER�yOTHER') DES CTION(CHOOSE TYPE BELOW) <br /> OIL BORING# I(� 52 11.F_i+-._k pit "'t LA-VI n_ I El <br /> UWER-BORE DIAMETER <br /> 0 WELL# RESSURE GROUT <br /> © OTHER ✓� _ GROUT SPECIFICATION <br /> COMMENTS:, at <br /> i`� rr r. ,. N "f e->! JItt7'i✓ Stbr�t lQ- u"f !s <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE2 ��3t ' <br /> iy�,?i� D MULTIPLE CASINGS [I MU L EVEL WELL CASING DIA <br /> fVA- <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS AZ& TYPE OF C G'.O STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑� ,MMUD ROTARY DEPTH OF GROUT SEAL _�/�� MIE TYPE TO BE USED[I AUGERS[I HOSE <br /> ❑O;AAIR PARGEiOZONE IYPyUSH POINT(GP OR CPT)_ GROUT SEAL PUMPE es ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING ❑HAND AUGER GROUT SP CATIONS YL t•r�� `6m <br /> O OTHER: ❑OTHER: OX BORING DEPTH d4 :40�e f. 0BOLTED TRAFFIC BOX OR 13 STOVE PIPE <br /> r ONOUC OR CASINO PROPOS 0 pt YES.esi speailiC Ms»mmme twcl <br /> COMMENTS: -1 t may- 1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT O CROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cern I have prepared IN a Ilcallon a d that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation 1 applica Is Ca o la aw . /� <br /> Signed Title/Company f :4 KJAd.l / E{�1 �p�g r�a¢.B-'V-I" Sj'44L , <br /> r •� N <br /> Print Name .^ Date ALL. p <br /> DEPARTMENT USE ONLY [ I �' O n v V') <br /> SITE MAP IN UNIT IV FILE;ADDRESS: .1-15 r'I fi< I>a-& -1 9 ��.{,e< r r T <br /> WORK PLAN DATED: 6 zS I O 4r <br /> APPLICATION ACCEPTED BY ��[, na-r�� DATEISSUED Ov AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY (A" DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DIT I ONS: <br /> ACCOUNTING ONLY: AID# FAC# / <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> Zgo t T9.00 cc - Oz5°IDYS (t,� 6 'Lfle t SR# S`{'}o(, <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> END Ia-0i 111507 WELL PERMIT APP <br />