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o`q�+N:<IFDR�'e` SAN JOAQUIN COUNTY FILE COPY <br /> Q a 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.sigov.org/ehd UNIT IV <br /> 4 <br /> WELL PERMIT APPLICATION ZEN• C� — <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 41115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's Z—Ido-08, <br /> Well Location ALE4U EVr'VevnoNT Cross Streets ` city S}DckdT N Zip Parcel# l5 3' <br /> Property A/ A T_ �— Address 2"/�� �i �''� � - city�ip t j ZiPTU Phone#�3 <br /> Owner . /T 1�7I�-�M)) ( ^^ __ --- <br /> C-57 Contractor rt 1( Address abs-D N-0 we, Nsk City ic# Phoneck '3% <br /> Consultant/Sub Cntr1y�/�C Address tCtUUCA Q ilCityto V-SyrU_ City <br /> SDTLS^1171ti- Lic# Phone`fi'D�9 3S�6J� <br /> GIS Coordinates:X ly5 Y 12'' •��(0 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW ELUBORING(CPT "')PROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [IDESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#_ '� El OVER-BORE DIAMETER _ <br /> WELL# -7 ❑PRESSURE GROUT <br /> ❑-OTHER n GROUT SPECIFICATIONS 1nV" <br /> COMMENTS: --alb--t-2b� S <br /> �0 <br /> TYPE OF WISI-L INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING )4 HOLLOW STEM DIA.OF BOREHOLE Z 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 1 O TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE 1 <br /> `❑-LAIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ASSOIL BORING µµ0 HAND AUGEERI_ GROUT SPECIFICATIONS %Q vt`I CA-,-4=A r__.e <br /> `/❑`OTHER: T.y OTHER: t�`� APPROX.BORING DEPTH "`� t '7-D ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> r CONDUCTOR CASING PROPOSED Qf YEs,list sp 1—tbns in comment saClm) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS ,n <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS Y, <br /> I 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 /> Signed Co1p'� �- Title/Company1�C( l 4 <br /> Print Name ✓ rU 1 k t� n[�. Date T —� <br /> j DEPARTMENT USE <br /> �,ONLY <br /> _. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � lJ�6 6 lLdKi'( <br /> WORK PLAN DATED: /// 2/ 200 <br /> APPLICATION ACCEPTED BY DATE ISSUED /'2-0I0 ARF.AQ" <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 PERMIT/SERVICE# INVOICE <br /> 50 � s ffl•� 3 3 � GtA� ? �•�3 s u 0 2 <br /> C-57WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> ��t 111SW(WEB) FILE COPY WELLPERMITAPP <br />