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o 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.www.siaov.ora/ehd UNIT IV <br /> F ` <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 <br /> �9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Well Locallon 549 I F g`1�et'J�cross sacci !off` 'e� city to, zp t 5304 Par ei#sso"s a80 Z2 <br /> Property /dlJ�c� LLG YfySSS.f1„,vwr44.5, 5/sc��«� �p9S2^L <br /> Owner �# <br /> MQ- �}E(A(Zy MOO Address GG 1' I' <br /> C-57 Contractor i�LtJ wrG D irVAddress c550 IZ� RA city <br /> /R��OV-r5�t� LIc#3IW'?Phone}off3-i— -4300 <br /> ConsultantiSub Cntr Apt ( Endirofe res, ItA4 puri hn Way City Gro t j Aver Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> E]SOIL BORING# ❑OVER-BORE DIAMETER `[} <br /> E WELL# f4w-iq ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 10 MONITORING ®HOLLOW STEM DIA OF BOREHOLE 1r [3 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA- <br /> 0 EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESSC 11. 40 TYPE OF CASING:❑STEEL N PVC ❑ OTHER 41 <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 455011 TREMIE TYPE TO BE USED❑AUGERS❑HOSE R <br /> f� <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:®Yes [3 No (NO/TE:MAXIIMU,M_FREE-FALL DEPTH IS W) �} <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ��r'f�QNQ (��►�uL►I.T <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH r BOLTED TRAFFIC BOX OR ❑STOVE PIPE (—* <br /> CONOWTOR CAS erG PROPOSED (d YES Rat apedke-1 is in om imm sel-', I \J v <br /> COMMENTS: f0 r'even ftatnmi I-- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. /� <br /> Signer �?14 Title/campany t r l'_D i'G f$iL W 1 R P%f <br /> Print Name Ir'! (-I I'`e J'111 DaIe <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ,` / 4 <br /> APPLICATION ACCEPTED BY /�/7Cfitd��a�i DATEISSUED <br /> �/ AREA J�S� <br /> GROUT INSPECTION BY 6c.wi.c f,4 (!w.j i�r `/ill-0 iui/l .IV II// FINAL INSPECTION BY /1l,/f DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> [ACCOUNTING ONLY: AID# FAC# <br /> ODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMiT/SERVICE* INVOICE <br /> / 3g9 y3y 3 033 39/69 CA`2 SR# 065919 <br /> C-57 P, WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2941 1I&W(WEB) WELL PEFWT APP <br />