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` .. <br /> (( <br /> nvlN, SAN JOAQUIN COUNTY j <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE ` <br /> 600 East Main Street, Stockton, CA 95202-3029 j) MITIGATION <br /> 7 .•' Telephone:(209)468-3449 Fax:(209)468-3433 Web:www sioovo/ehd UNIT IV <br /> I` WELL PERMIT APPLICATION <br /> FILE COPY; <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r}, Ip ton is made in compliance San <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applica <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. t <br /> €. it Assessors <br /> j Well Location 35`41- %J- Ak"+Mcx-l-+" Cross Street M el A«"Pri -- City S-a-M i'clAn ZiP•9SZ,9 Parcel.# 041- <br /> Pro <br /> 41 180- 14 <br /> Properrttyy,, <br /> Owner-rQ� � - +r•4 I.l.l- Address 4' City-Q"A"" Zip 3 Phone# <br /> 4.° q II '# aucPhon 3t3—S-Sbp <br /> C-57 Contractor �irw„gc.11l� Address 'So 110.,x- �•�. City T�hrF�AG$ - Lic# g <br /> «I ,(� � �� �g25)`ilb-5300 <br /> Consultantisub Cntr hf[r.�0a.NiI Address�.t ,*&Se w- .�..I� City"Acs, V" ^ Lic# Phon I <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED:- > <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ;&SOIL BORING# ❑OVER-BORE DIAMETER-.. <br /> ❑WELL# ❑-PRESSUREIGROUT <br /> ❑'OTHER _ GROUT SPECIFICATIONS <br /> COMMENTS: - j <br /> it ln <br /> .. ( <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS- 1 <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2/` ❑MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:_ <br /> it <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC 0 OTHER <br /> L i <br /> Cl VAPORk ❑MUD ROTARY DEPTH OF GROUT SEAL -G[7/ TREMIE TYPE TO BE USED 0 AUGERS❑HOSE <br /> it <br /> 0 AIR SPARGE/OZONE - O(PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30J <br /> tp <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> !� <br /> ❑OTHER: 0 OTHER: APPROX.BORING DEPTH YD) (:I BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (AYES,list spssiBrafians in comment sedlon) <br /> COMMENTS: -F <br /> I1 <br /> ;NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS (t, <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 1 - <br /> Regulations,and applicable California Laws. - <br /> Signed :a - Title/Company lout r 1-6,0-w�—/c-Arc rtyaOi <br /> Print Name• .. yG--c F•d� Date �i , .PlI1�/OZ <br /> r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: .7JrSS 1/1Ie$f Hamm e r n'e <br /> I <br /> WORK PLAN DATED:_ Mwv 1S aoo9l {�, _n - <br /> APPLICATION ACCEPTED BY lI) �, I QYt Q L IYl(.4dr+n PtJ — DATE <br /> )ISSUED1 1a '.2I -O 9 AREA S I p <br /> GROUT INSPECTION BYyt Phil!I A IA& ¢'. -I I y ' 111 FINAL INSPECTION BY DATE/-/ -/D <br /> DESTRUCTION INSPECTION BY,,`` m �1 fr DATE <br /> Fta <br /> COMMENTS/CONDITIONS: d"riP P�� AT tlT!-S)ie d ry!6 SBS(o r• na 11 S13 6 - <br /> y, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE_ PERMIT/SERVICE# INVOICE <br /> 36-O 89.oD QR. DO 3G4s /2 21-04 SR#OOS9olb <br /> C-57 WC -WAIVER - C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 20A1 11/5/07(WEB) <br /> ., WFLL PERMR APP <br />