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ppYMEµT <br /> RECEIVE <br /> SAN JOAQUIN COUNTY FEg 0 6 2012 <br /> ENVIRONMENTAL HEALTH DEPARTMENT sN+JOAo°ON �"^ <br /> Etm SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 HeALTMDEW MITIGATION <br /> Telephone:(209)488-3449 Fax;(2139)468-3433 Web:WWW-sioov,orD/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 Heahh Department. <br /> Weil Lotion 2.4 +,, <br /> 9I . —Cross Street W- W 61t� & City Zip 15_ arcel#rltta-0W -!& <br /> Property �--t 1 ono c t• <br /> Owner f VN.-vNI V Clij%T^�2��1' Address �0• (80K ��_a t City Zip�C3 S Phone <br /> C-57 Contractor Y 'I i� .iw r''_K 1_"f^Addiess'301,f �/ [>,k �1]'C liL �. City fsM - �I�, Zip �la Lic#��70L{ hn,g <br /> Consultant(Sub Cntr LtB' �_ AddresS33p9 .S�YUS TC City M� ' Li +�C74SPhone �nq,%k%',Krf.`t_1b <br /> GIS Coordhnates:X -I�+�2 -"W%' ,Y 3'i 71 1 f�>�1 ,Township --ILL t <br /> N Range_ Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GE07 E,HYDROPUNCH HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW} <br /> SOIL BORING# jL SPP I r-4 C-1(��--. ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> ❑'OTHER �" GROUT SPECIFICATIONS <br /> COMMENTS: �1�� �� k14'.'r ?+GS]Q. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE -e ❑MUi,TIPLE CASINGS❑MULTI-LEVEL WELLCASING OIA'_ <br /> Q EXTRACTION El AIR HAMMER/ORIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL �✓-�! TREMIE TYPE TO BE USED D AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH PO4NT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS NQ*-tC&�:ll_�• ,_-„_ <br /> ElOTOTHER ❑OTHER: APPROX.BORING DEPTH 3-5f ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS CONDUCTOR CASINO PROPOSED„--,_ _ (it VES,IW spncifiwGons in cwmnnnt.1i,n) <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�alla�ppsi{c}a1ble California Laws. <br /> Signed TigelCompany <br /> Print Name _ (�. LAre <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: .Z. 1 L 1 F1.t t.WP�.��+• _ <br /> WORK PLAN DATED: n/A- <br /> APPLICATION ACCEPTED BY_ _, ,„„ DATE ISSUED Z b//-____-".-,-,-„AREA,.,__ <br /> GROUT INSPECTION BY a 9 'Z-- FINAL INSPECTION BY TT�r"�� DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# __ FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVD BY DATE PERMITISERVICE# INVOICE <br /> a o" - *52'0 — 112- <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT -yam ENCROACHMENT DOC <br /> EHO29-01 11b07 WELLPERMIT APP <br /> A"r t� 00 3 6 zo, P(� S 3 5 o g,(, <br />