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► vFILE GUV I <br /> USAN aJOAQUIN COUNTY <br /> Qda zj, Y ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> m v 600 East Main Street, Stockton, CA 95202-3029 MITIGATION i <br /> c p Telephone:(209)468-3449 Fax.(209)468-3433 Web:www.sioov.org/ehd UNIT IV ' <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {7y.12 <br /> Application is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is`made in compliance With San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San <br /> �Joaquin County Environmental Health Department. <br /> +h c 1__ 11�JT• 4'HUMI iy'r City 1 L Zi Pancel or'�p <br /> Well Location 595 �� ��I J ttc� Cross Street �Zip rJ�J7 Parcel# `33�3 ' <br /> Property, ,t y� \ t� -bo /- <br /> Owner 1" lY- � L71Ctt In Address Y6 +JV1L IW31 City�rt4i`1Dod.. ZipaL}513 Phone# <br /> I' i <br /> C-57Contractor VIrDn:ex. Address 5292��"eCABW6, City Pftth eC.O Lic# 7�5T7Phone(g2,5)5_2l-I`t�CIi0 j <br /> Consultant/Sub Cntr {I., l.h YD YYI Addressz�rJ( Tc.�,ORUbA`�- City ItoPt Lic# t55i 5bt Phone 33.OW� <br /> uv'"s Irx�.1 tL <br /> GIS Coordinates:X�- ,Y 12�. 1 ,`Township Range Section <br /> .WPRK TO BE PERFORMED: <br /> )S NE"ELL/BORING(CPT r--noROBE,HYDROPUNCH,HAND-AUGER,OTHER`) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> X SOIL BORING#_ ElOVER-BOREDIAMETER <br /> ❑WELL# - ❑ PRESSURE GROUT <br /> El-OTHER ROUT SPECIFICATIONS <br /> COMMENTSr <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )/// <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTIONS ❑AIR HAMMER/DRIVEN CASING THICKNESS .TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> Q VAPOR [j MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED El AUGERS d HOSE <br /> ❑AIR SPARGE/OZONE Q4.PUSE POINT(GP OR CPT)'_GROUT SEAL PUMPED:❑Yes)6 No (NOTE:MAXIMUM FREE-FALL DEP IS 30') <br /> ❑SOIL BORING '❑`HAND AUGERS GROUTSPECIFICATIONS ✓ ' f'" <br /> OTHER: ❑OTHER: - APPROX.BORING DEPTH 25 ❑BOLTED TRAFFIC BOX OR CI STOVE PIPE <br /> GP CONDUCTOR ASING PROPOSED (If YES,list specifications in comment section) <br /> COMMENTS: Injs /,Jt� .j - tA6 <br /> NOTE: OFFSITE BORIN RE UIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 hav .Irepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all al tic hi a Califor <br /> Signed C — Title/Companye$ldeJ'1�J �IV.�LC{I (_j'ttiYorlmP[1} 17Scrv�e�s fir . <br /> Print Name nc-k Date II 121 2C*8 <br /> DEPARTMENT USE ONLY L) L �-c- J� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �/S -E. . YA- UL L� L U <br /> WORK PLAN DATED: - 5x,410ir - <br /> APPLICATION ACCEPTEDBY - DATEISSUEDE2rl,' 1 AURE <br /> GROUT INSPECTION BY FINAL INSPECTION BY DERN44zCf DI/1r`Er75kTE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS:' <br /> ACCOUNTING ONLY: AID# - FAC At <br /> PE CODES FEE INFO All REMITTEDCHECK# R V'D BY DATE PERMIT/SERVICE# INVOICE <br /> 657 <br /> 5zs-0t tvsro WC El -WAIVER C57 LETTER OF AUTHORIZATIONT O SIGN RMI EN�{2Q#AC�vl�l`DORMITAPP <br /> r U <br />