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o�a�tN man Joaquin County <br /> a i<ronmental Health.De artment SITE <br /> t <br /> '0 600 P.-Main Street, Stockton,CA 95202-3029 MITIGATION <br /> r,�.! 4 IP 8-3449 Fax: (209)468=3433 Web:.www.sj90V.org/ehd UNIT IV <br /> , , „ �. HEALTH Well Permit Application <br /> res an i,/S)E9 'cF <br /> . :,,���Nvk�FUNDABLE 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 l <br /> Joaquin County Development Title;Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 1 �7 S}Yt Cross Street City Zip 450(53 Parcel# 0 -Os <br /> { PROPERTY <br /> OwnerRlJIW)nnn Om;nLL,T. Address, PO [�iU(t2-1 City RL'I'lo _—Zipq V-_7.0 Phone# . <br /> F C-$7 Contractor! 1!QrNLd AMLnWMMUkjk Address a City YFr,ra��n ZipRS�IS Lic# Phone#I00�i1:�1, ibbfv <br /> ,. i <br /> i Consultant I Sub CrrtrAd -a#get,tnjAyujMa&LLtw Address et City,g4m0!ki Lic# f'ukQag-r Phone# (jCd1 gkj--bdp _ <br /> ) <br /> GIS Coordinates:X YTownship Range Section <br /> WOR TO BE PERFORMED; <br /> ,gNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) .p DESTRUCTION (choose type below) <br /> -OSOIL BORING# '3V 1 gV 0, Sd3 3Uy OVER BORE. DIAMETER <br /> 0 WELL# - 0 PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> ' COMMENTS: <br /> _TYPE OF INS ALLATI N TYPE CONSTRUCTION SPECIFICATIONS <br /> d MONITORING 0 HOLLOW STEM DIA.OF BOREHOLELA5' 0 MULTIPLE CASINGS 0 MULTI=LEVEL WELL CASING DIA: <br /> 0 EXTRACTION B AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC .0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5+ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes. '8'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> JrSOIL BORING a HAND AUGER GROUT SPECIFICATIONS� L1>r 1�orlIlYr1[I NPG'ci � hlPYi4 <br /> 0 OTHER: p OTHER APPROXI BORING DEPTH 5 hs�r _ 4 D:BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Ob (if YES,list specifications in comment section) <br /> COMMENTS: <br /> f <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT.PERMITS. <br /> t 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> .I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin <br /> County Ord' anc RuIgs and Regulations,and all applicable California State.Laws. 1 <br /> s Signed x Title/Company_LU, 1�i05rcl<[f t4 /!Mwr idf C'1('C <br /> Print Nam' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ P?K' Ak <br /> WORK PLAN DATED:. e-t- O <br /> Application Accepted By *bate Issued s v " Area—l � <br /> 1 Grout Inspection By Date�- ZL Final Inspection By Date <br /> Destruction Inspection By Date <br /> I COMMENTS/CONDITIONS: l e)jp + " <br /> I ACCOUNTING ONLY: AID# FAC# <br /> ;PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR# <br /> C-57— WC -;WAIVER-- C-57 Letter of Authorization to sign permit—'Encroachment doc. <br /> f EHD 29-02-001wcb <br /> 6b3 d ` " <br />