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° nrySf °o� SAN .IOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 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 UNIT IV <br /> WELL PERMIT APPLICATION RE���� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �1 ,,//��ED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appli alio is ma e in®cohipk911ce with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health <br /> Well Location j//1 J/. F;Iieif ri Cross Street C• l✓eiei Ae City SJ2"/r fon Zip 955'Y(I�T� <br /> Property< ' .�_ <br /> Owner_ d✓ /?f�rw Address Cityr 'iP9s?OZ Phone# <br /> C-57Contractor k5l &.11rn Address 220. Al. 6ay7 5/. City(„yew//d..o/ Lie# eZ339Phone(Wder-292. <br /> Consultant/Sub Cntr �ddress 9,/0 �/ero ,164,Lid. City ass Lie# Phone"Fo a72-V..200 <br /> GIS Coordinates:X 3!7-%0 Y 121 2-53 ;Tovmship,, Range Section <br /> WORK TO BE PERFORMED: <br /> Lff NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑,SOIL BORING# ❑OVER-BORE DIAMETER <br /> [✓DWELL# f1 L,-015-f!161-111$ 1111✓ -DI 5-)SSD - [J PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 19 MONITORING 9 HOLLOW STEM DIA.OF BOREHOLE .7 D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> ❑ EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS S/iec7a@ Sr0 TYPE OF CASING:❑STEEL PVC El OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL60' TREMIE TYPE TO BE USED POAUGERS C3HOSE <br /> O AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:21/Yes.❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30} <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> El OTHER. ❑OTHER: APPROX.BORING DEPTH 6O-S�S 2/BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR"INSPECTIONS <br /> I <br /> 1 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 applicable California Laws. <br /> Signed Aw q� Title/Company Sfa/'>r 56;v„1,;7r /T/ie_ <br /> Print Name /'Txm /,ylu�,.n Date -On/0-7- <br /> DEPARTMENT USE ONLY" r Tr 35,2 6 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0 f <br /> WORK PLAN DATED: // �pi <br /> APPLICATION ACCEPTED BY D[�7E,�. ,E, AREA oL7• /q <br /> GROUT INSPECTION BY FINAL INSPECTION <br /> nn irufii7 DATE 3�Zj-vt <br /> DESTRUCTION INSPECTION BY DATE <br /> e <br /> COMMENTSICON DITIONS:' <br /> t <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 le WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br /> EHO 29-01 11/5107(WEB) <br /> WELL PERMIT APP <br /> II <br /> I <br />