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SAIF JOAQUIN COUNTY �. <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> '' 600 East Main Street, Stockton, CA 95202-3025 MITIGATION <br /> Teiephorte: (209)468-3449 Fax:(209)468-3433 Web:Wv,1W.8iGUV.Llra ehd UNIT IV <br /> WELL. PERMIT APPLICATION <br /> NON-REFUNuABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Count)'for a permit to construct and/or install the work described. This application is made ir.compliance with San <br /> Joaquin County Development Title,chapter 5-1115.3 and the Standards of San Joscuin ounty Ervironmental Health Department <br /> v 5 �'aw• IIvD W•��en+".4,-�.s.-0 Assessor's_ <br /> Well Location 3• ��arr•, � d'Cross Street I t N�r+��-' L N nB.. City 5+-c 1�7V-1 Zi Parcel# O 1?-4 "0 Z •7 <br /> PropeOwner r e e 0 eublC. T! p -� - <br /> tSNO VNw- <br /> i Address D• l? c;C to 10 City,Gv�c:�1 )1 r, c+`. fir �Z5Fl Phone?' ;. <br /> .._. 9 -,gin' 3(G'1- L 'tGG <br /> .......___.._..-_-.._.__ _.. _ <br /> C•57 Contractor Address �'° ��0-Wcity ° d Zip ° Z`il Lic T 2 0 u D q Phone 9N vo <br /> ConsultenVSubCntr (9 -Zero Address t-7/q Jin c• ^• Sr• City Lic0 Phone ?3 - 9'V K " <br /> GIS Coordinates.X Y Township Rarge^ Saction <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROK,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE-TYPE BELOW) S <br /> Q SOIL BORING-, OVER-BORE DIAMETER_ " <br /> ❑WELL# PRESSURE GROUT <br /> L`OTHER GRO'J?SPECIFICATIONS Pt irr ma ti <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE yONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _ >j ❑MULTIPLE CASlt,'GS❑MUL71-LEVEL WELL CASING MIA:— <br /> EXTRACTION <br /> IA:__EXTRACTION ❑AIR HAMMERfDRIVEN CASING THICKNESSy A TYP[OF CASING:G STEEL ❑PVC ❑ OTI IER <br /> F i r <br /> ED VAPOR C1 R1UD ROTARYDEPTH DF GROUT SEAL ID j! 1 TREMIE TYPE 70 BE i11.3ED Q AUGERS El HOSE <br /> 0 AIR SPARGEIOZONE Ci PUSH POINT(GP OR CPT)_ 3ROVT SEAL PUMPED.M Yes/❑No (NOTE:MAXIMUM I FREE-FALL DEPTH IS 30') <br /> u SOIL BORING f]HAND AUGER GROUT SPECIFICATIONS <br /> Ci of HER., ❑OTHER: APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> 1 / CONDUC>SW=PROPOSen, -__ {if YEE,fist 5yee;lf ceti;;:y'v;cFn;r�e;;t sectio.' <br /> COMMENTS: yA�✓ /! < j r <br /> NOTE: OFFSITE BORINGS REQUIRE kCCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules ano <br /> Regulations.Iand all applicable California Laws,- <br /> Signed <br /> aws. _Signed 4,�`� -- �J��;'--1% Tike/Companv s' jt' Lf-em'09 is ! (rr-nv�C� ie�0 lr1At�SII <br /> Print Name J°e-. �I�.Sa V �+'Zl Data ?Z0 8" <br /> /!(� DEPARTMENT USE ONLYl <br /> SITE MAP IN UNIT IV FILE,ADDRESS: l q0 W, �w <br /> WORK PLAN DATED: JAN- <br /> APPLICATION <br /> ANAPPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION 3Y tJA/ - " ' y FINAL INSPECTION EY (C AA-O--, DA7E <br /> DESTRUCTION INSPECTION SY/,)[. eco DATE G 2-7 <br /> COMMENTS,'CONDINONS: L c�P Stu /� �i _ r1 ✓ �.0 v , ,, - S ,n�e�t c it,�C cLI c. ��C to�7�,��' _ <br /> ACCOUNTING ONLY: AID# FAC# <br /> [PELCODESFEE INFO AMT REMITTED CHECK# I RECV'D BY IDATE i PERMii1SERVICE 9 1NVOICL <br /> O1 '� 9D <br /> C-57 WC -VYAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107 WSLL PER01 APP <br />