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_ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> • UNIT IV <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www si4ov.oro/ehd <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! and the Standards of San Joaquin ounty Environmental Health Department. Assessor's <br /> � v.e�, Ir+�o w-ld � -1-7-1 y o-Z 7 <br /> Well Location -7 913 5 ��r,4-vv,, 9 d•Cross Street f-#r r t \*-� L ti r� City 5�a[ k{v✓I Zip Parcel# <br /> Property p.0. (3 o�C b H 0 City W�o�b r Zip `(5 Z 5 8' Phone# toy- 3(c7- b 5 9 Z <br /> Owner �ejocablf .l r S} Address Slrq 4doo <br /> C-57 Contractor <br /> V`�In) T),-.\I-,, Address P o. �ox 01 l D City L d Zip q$Z y j Lic# 710 r{O H Phone <br /> ZQ�u Address 17/q AA ^ 5�• City ES to/u v. Lic# Phone F3 Fr - �I �s 8 k <br /> Consultant/Sub Cntr (71'0-1e18 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> El NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION(CHOOSE TYPE BELOW) <br /> Ll SOIL BORING# OVER-BORE DIAMETER fS <br /> [I WELL# PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE k" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS A/A TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL �D S / TREMIE TYPE TO BE USED P AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:'Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING El HAND AUGER GROUT SPECIFICATIONS /U(- 4- �Q r� �� CI et"' T <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCT F ING PROPOSED (if YES.list spermcations in comment section) <br /> COMMENTS: �W (� <br /> NOTE: OFFSITE BORINGS REQUIRE CCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 ap\p�icaable California Laws. L I I <br /> Signed x/00 cl Title/Company 5+0� Ueo�o9 /ST / (T✓°v^C ZE^U rlG�rSiS <br /> Print Name 30e— v°t lA Date 5�VO <br /> /// DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: //go <br /> 7 y Wn �rntn o—fc <br /> WORK PLAN DATED: ` (� <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY r� FINAL INS-P`ECTION Y q DATE <br /> DESTRUCTION INSPECTION B DATE L7 / <br /> 1 / T <br /> COMMENTS/CONDITIONS: L OF Sdtr • l��Z�f <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Z (�70' ( 0- 017 yo� SR#COSVql <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />