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QUIN <br /> UNTY <br /> ID <br /> SAN OAHEALCHODEPARTME ,, 18 WED S� ITE• <br /> a a % ENVIRONMENTAL <br /> 600 East Main Street, Stockton, CA 95202-3029 DEGr� Z MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-343 3Web:www sioov.ora he 009 UNIT IV <br /> "11tl/1F ALM <br /> WELL PERMIT APPLICATION i <br /> It C�p <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 9-1115.3 and the Standards,of San Joaquin County Environmental Health Department.11 Assessor's <br /> Well Location X55 v1.A&.imtw Ln. Cross Street rlo,c,Atr5-D6w City bk� Zip S9�S Parcel# O�-t'1"��7A <br /> Owner ',4. `�o� li,.�"u-Ids yti53� Phone# <br /> l Property 1 � Zip• <br /> n -n..� Address 456}F �ke�cisASF City��� <br /> Ir <br /> j; swlo <br /> C-57 Contractor C.�•es�A +sr.� Address 9� koO, city �'tnr}:,"Ye-Z- Lic#y051bS Phone 9'2S 3�3 <br /> " .nEO+y -Lic#" Phone59S %ts3� <br /> Consultant/Sub Cntr hTC.PE6ou�s\t) Address 61609QOY.1S�CitK City�ti•54 <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: - A <br /> X NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH HAND-AUGER,OTHER-) - ElDESTRUCTION(CHOOSE TYPE BELOW) <br /> ,SOIL BORING# I ❑OVER BOREDIAMETER <br /> ,WELL# ` 1 - El PRESSURE GROUT <br /> ®'OTHER C s+o 2,w GROUT SPECIFICATIONS Cv^` <br /> COMMENTS: - - <br /> ;I <br /> TYPE OF WELL INSTALLATION TYPE- CONSTRUCTION SPECIFICATIONS ,; r <br /> ,MONITORING 0 HOLLOW STEM DIA.OF.BOREHOLE 2� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: L <br /> 1i <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL (ZPVC ❑ OTHER <br /> G <br /> [I VAPOR ._j. [I MUD ROTARY DEPTH OF GROUT SEAL✓ LAO, TREMIE TYPE T BE USED(].AUGERS(�MOSE <br /> El AIR SPARGE/OZONE -❑ 0eyes PUSH POINT(GP OR GROUT SEAL PUMPED: es O No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') �l <br /> 19 SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS I V <br /> ❑OTHER:_ ®OTHERIKA(T'u� .BORING DEPTH 't0 N BOLTED TRAFFIC BOX ❑STOVE PIPE <br /> I CONDUCTOR <br /> `4 <br /> CONDUCTOR CASING PROPOSED (if YES,list speci(ra6ons in comment section) <br /> COMMENTS. Se, rinw A-o stbl � t-l>'.n�y-aria tacSl w 26" �Y m 2S1-2S' <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS '{r - <br /> I hereby ceitity thayl:have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, alifornia Laws. <br /> Signed � <br /> Title/Company­iVose- IA i <br /> Print NamDate <br /> ltT� �SDe;0.t y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3S5S ,IW Bs 1 Pam rn BY Lar" te. <br /> .WORK PLAN DATED: ND Vern b EY 4. 1 00 9 <br /> I , r <br /> APPLICATION ACCEPTED BY � � _L M e DATE ISSUED f/.Z•����/-�0yq"� •AREA .145 <br /> GROUT INSPECTION BY�1,;At#]Pi A!J)r!6&N 1. 14.10-301 INAL INSPECTION BYy1 C'FO�iQ m/L/J/+� g DATE)-0-A) <br /> DESTRUCTION INSPECTION BY - DATE ll <br /> COMMENTSICONDIYIONS: AOI Vn YI e.ev Pira erf soil I70Y 1 n j S 84 and 1 nSf-a 1l,2�;ort -.J M W-'.11 <br /> if <br /> ACCOUNTING ONLY: AID# - - FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE 'I PERMIT/SERVICE# INVOICE <br /> X505 gq,00 89. 06 3465 �/m 1221- o9i SR# 005901 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD N41 1115/7(WEB) - WELL PERMIT APP <br />