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SAN'JOAQUINCOUNTY :/ E COPY <br /> - ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 1 600 East Main Street, Stockton, CA 95202-3029 r <br /> ��klephone.(209)468-3454 Fax: 209 468-3433 Web:www.sIgov.org/ehd <br /> ( www.s 1.Qov.o€g_hd MIT{CATIONUNIT IV <br /> lP R 0 1 20.10 WELL PERMIT APPLICATION , <br /> ENVIRQNME-NT 11FALTIi NON-REFUNDABLE'PERMIT EXPIRES I YEAR FROM DATE ISSUED Jam! <br /> Applies T�14 15 Joaquin County for a permit to construct"andlor install the work described.:This application is made in compliance With � <br /> 3oaqu�tgtbe�'i T� l � AA glance €t San <br /> € ..chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department: <br /> Welf Location x2� -C•�1►�+ewvl ' !° i r Assessor's <br /> ros Street_ : yu.� City ' Zip RSA Parcel# ttt�-t•�P"�� <br /> Prope ` -- <br /> Owne X10. Add ess 2 5i.'Fyey Q �j{, cityzip Phone <br /> .n o <br /> C-57 Contractor AoauJottwltress �(� 1ROsvlCttictik Cit ,GY1fttRQ 3�S(zip 9�i6I9 Lic# 0431,7q Phone <br /> rr ' !' j ' <br /> Consultant! V►Y VMt3tlressI u3� ti t CLichon�f <br /> ,..; <br /> GIS Coordinates:X Y Township 4 N Range LQ 15- Section W4' <br /> WORK TO BE PERFORMED:- - <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND.AUGER,OTHER-) .. DESTRUCTION(CHOOSE TYPE GELOW) <br /> El SOIL BORING# OVER=BORE DIAMETER_ <br /> Cl WELL# — PRESSURE GROUT _ M VV CP <br /> ❑*OTHERA I i j I GROUT SPECIFICATIONS VAM CaYN,co_'b <br /> ❑EXPLOSIVES DETONATING CARD_ - <br /> COMMENTS: P <br /> TYPE OF WELL INSTALLATION TYPE i CONSTRUCTION SPECIFICATIONS <br /> (t N <br /> PPAONITORING 'NMOLLOWSTEM IDIA,OF B6REHOLEE]:MULTWLE CASINGS D MULTILEVEL WELL CASING DIA: <br /> ❑EXTRACTION ©AIR HAMMER/DRIVEN CASING THICKNESS 51r(,t If 0 'TYPE OF CASING:❑STEEL V__PVC ❑ OTHER <br /> E]VAPOR EJ MUD ROTARY REPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARG&OZONE yo ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes-❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> G — <br /> ❑SOIL BORING ❑HAND AUGER. GROUT SPECIFICATIONS r' <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE.P€PE <br /> CONOUCTOR CASING PROPOSED _ � (A YES.€ist sr ecirications in comment section) <br /> COMMENTS. _ <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS' <br /> 48 WORKING.HOURS NOTICE REQUIRED FOR INSPECTIONS � <br /> a <br /> hereby certify tjat I have prepared this application and that the work will be done I accordance with San Joaquln•County Ordinances,Rules and <br /> Regulations,anq jail applicab Ca ifornia Laws. a , <br /> Signed TitlelCompany r�,tA CSS jo or Vt-YVUw,,-U+W iwe <br /> Print Name C� D . �� ' hate 'LS l0 <br /> DEPARTMENT USE. ONLY7. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY 4 DATE ISSUE <br /> b AREA ©C� <br /> GROUT INSPECTION BY FINAL INSPf CTION B DATE' <br /> DESTRUCTION INSPECTION BY DATE .�30 16 <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID#' FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE jPERMIT/SEPVICE# INVOICE <br /> Mv <br /> C-57 iWC _-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _E T DOC <br /> EHD 29-01 10/28,109 . ,5 . r. , WELL PE ITA P <br /> ww - „F I L O <br />