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,o t,h • SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> a, <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.orG(ehd 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ^,, Assessors <br /> Well Location 9R 3 W. L.(+ St_ Cross Street IU• mAcY�R}4,or ISR. City �'2 P, `t Zip �o� Pa•r�l# a50-140- 03 <br /> Property <br /> Owner (1.lil l"A&% Dor3K Address 115'C) 2a•t laY\ IHR. City L44er CtrcL Zip gS485 Phone# O(- 7?'( <br /> C-57 Contractor Addressa�c,nn City/n Zip Lic# Phone <br /> Consultant/Sub Cntr 54-mr4ec- Address 3011 k - ]MAf;or - City(cAAkl- "o , Lic# Phone Cq I(PSB(al'Of-I(x) <br /> GIS Coordinates:X 37.'I 3$S if j ,Y-12.1. c{I Z3 o Township D Sou Range 5 6A.5'1- Section Z2. <br /> WONINEK TO BE PERFORMED: <br /> W WELLIBORING(CPT,GEOPROBE,HYDROPrtj.1CH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [ErsolL BORING# CSD-1 ±InL 6 (.;$8-(¢ ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE '^,," 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELLCASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS ter(W TYPE OF CASING:0 STEEL ❑PVC 0 OTHER <br /> 0 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL PA(A TREMIE TYPE TO BE USED 0 AUGERS❑HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> O'BOILBORING EYHAND AUGER GROUT SPECIFICATIONS f'�eClc Cern 41Z <br /> 0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONCUCTOR CPSING PROPOSED (If YES.list specirwtbns h comment section)) <br /> COMMENTS: Cvt.F` mal-:on bort n�f r_ -t( i� abnr�cL .0 n G o��,1ec ,•c{.�-e' JL i.l.l� roc conwn,b <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all <br /> napplicable <br /> eCCalifornia Laws. / <br /> Signed �/3V L. P. 106L - — Title/Company ��1012. �TGO�Oty,}{ / ST7 <br /> rwr4ec <br /> Print Name _ Y\Azic-.. 7• 3 Wt2cz Date 5- t"L- O•S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _ Ff 2-0 3 W. <br /> WORK PLAN DATED: `1(1}61g, <br /> APPLICATION ACCEPTED BY DATE ISSUED 13 bfj AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 2q0 ( 1� ".0 v 1vI y} - U 5 03 fva I SR# 5822.4 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD730111407 &)If� 0`15 y16 <br /> WELL PERMR APP <br />