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- SAN JOAQUIN COUNTY <br /> 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.s'qov org/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 9 115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> q, (1140 w- I Assessor's <br /> Well Location 8 3 5 (w R c�• Cross Strel He,V—AA e L m.4 t' City S+o c k lw� Zip Parcel#(r 2 Z 7 <br /> Property k,e r1e5 Www; y <br /> Owner T✓,%+ Address City Woodb"`,'J .t Zip g52SfJ Phone# (Zo9) 3b7- eQyZ <br /> C-57 Contractory r.) D,: Address 0 i3 07` 9-1 G City 1-0 cl Zip 9 5 Z y I Lic# ? 0 90y Phone <br /> q 9buti <br /> e <br /> U,rav d Ze,161 <br /> Consultant/Sub Cntr—A r"1:1 f,; Address I'71 '-1 MA's S+rl?C } City E S C u i tl Lic# Phone 8'7 b- '9*eLfr <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 51NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# M W 1 1 ❑PRESSURE GROUT <br /> [I-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 1R MONITORING gJ HOLLOW STEM DIA.OF BOREHOLE +' <br /> /^ ❑MULTIPLE CASINGS E]MULTI-LEVEL WELL CASING DIA: Z �I <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Se-14. LIl7 <br /> TYPE OF CASING:❑STEEL 7ER PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Z ID / <br /> TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED: <br /> CR Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS til*-a�- Ce [ A4- V/ v— V v+- <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 6 / <br /> BOLTED TRAFFIC <br /> CONDUCTOR CASING PROPOSED BOX OR [I STOVE PIPE <br /> COMMENTS:At � (if YES,list specffications in comment section) <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 Califomia Laws. <br /> Signed -4— \j t,13 — // <br /> r Title/Company S�w�F U t o j p 9 j r be VN Y e w <br /> Print Name J o e- �/ w� ( AH a//s i S <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE;ADDRESS: 7y �. <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY DATE__I SUS AREA 99 7 <br /> FINAL INSPECTION BY flZ 7) <br /> DESTRUCTION INSPECTION BY DATE DATE <br /> ��`` <br /> COMMENTS/CONDITIONS: t-l7tO <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO FAC# <br /> AMT REMITTED CHECK# RECV'D BY DATE <br /> PERMIT/SERVICE# I INVOICE <br /> C-57 WC -WAIVERO1 <br /> 7 9/0 <br /> UO SR#QO�y�I�� <br /> C57 LETTER OF AUTHORIZATION TO SIGN PE MIT <br /> EHD29-01 11/5/0 _ ENCROACHMENTDOC <br /> WELL PERMIT APP <br />