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• ,� I FILE COPY <br /> SAN JOAQUIN COUN I.yT SITE <br /> � tENVIRONMENTAL HEALTH DEPARTMENT <br /> ��Q 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> SEP JTQhone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �IyVIRpNPiI +�'� 'i aL"'t1 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 O� C7 <br /> Joaquin County <br /> /ntDevelopment Title,chapter&1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's <br /> l AD CI.-l;;.DD � <br /> Well Location O,zk` c,�1n Cross Street IN��ttx.)LXY City C1�r�C�—Zip Parcel#OS p- In- 0 - <br /> ownertyQ„rbbSYDacFS r,(aWL�M 1l0 city D�1 ZipgU' K3 Phone# <br /> Owner :aU SCNY SS Lt°.t :'1E� Address 1vL (r[Tl_ 7 s, <br /> C-57 Contractor AddressM <br /> I'�,yL--/. / Ci G1. Lic®t'65 Phone G� 313 Qi OConsultanVSubCntr _ Address ��Z�� �'�'� City y� Lic# Phon 5 lL1� 7 ,Y — .Township Range Section <br /> GIS Coordinates:X 3� 1 <br /> WORK TO BE PERFORMED: <br /> IN NEW WELLIBORING(CPT,GEOPROBE,HVDROPUNCH,HAND-AUGER,OTHER') [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# a.-C P-C' i-' HvAro�uNch -VV IZ l CI,*jtr ❑OVER-BORE DIAMETER <br /> ❑WELL# yyt�NCod ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> C•'11tj -r-v-umks • � � <br /> - T aPro )o S <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4 ttN 1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIi <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 'v TYPE OF CASING:❑STEEL C1 PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARV DEPTH OF GROUT SEAL lIDDepY1 TREMIE TYPE TO BE USED❑AUGERS❑HOSE CID <br /> ❑AIR SPARGFJOZONE PUSH POINT(GP OR CPTc I_GROUT SEAL PUMPED:❑Yes We (NOTE:MA� /vXIIM�U�M FREE--FALL DEPTH IS 301) CPT-N d <br /> ^�/'C', u <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> F wr/v`-'T - CCT `moo r%I <br /> ❑OTHER: ❑OTHER' APPROX.BORING DEPTH - [I BOLTED TRAFFIC BOX OR [ISTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (i(VES,list 1.a1C3lims to c"ment swim) <br /> COMMENTS: <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 all applicable California Laws. <br /> Signed �D Title/Company Cori <br /> Print Name 56P-V1- VYI Date q- O -L) o ' <br /> DEPARTMENT USE ONLY �cLLlLl� � u e- �tc4- v- yob <br /> C � � vv1c� C-I4- atSYl� <br /> SITE MAP IN UNIT IV FILE,ADDRESS/::-- <br /> WORK PLAN DATED: �Pr <br /> APPLICATION ACCEPTED BY DATE ISSUED - / AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY l. . ?_ DATE I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMME NTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMTREMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> p j 2-01 ,5& q—I5 o g s oo <br /> C-57 WC V -WAIVER 057 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> AUYV <br /> EHDY801 11I5N](WEB) FILE <br /> ' EWELL�ERyt 1IT?y <br />