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SAID JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTM N SITE <br /> ' { 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 9 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. <br /> + , �`� q S•(YIM,J Assessor's <br /> Well Location Wu-h1� "r Gross Street S� mAn►J City YY1arJr�e. Zip 9533-r Parcel# X19'326,'7,3 <br /> Property ,.�/1 n Hlka.)%UA Zi 5317 Phone <br /> Owner Cn� 1 1 IAr�1,�f.�� Address �l�l`u 1 I I�• l"E.nli"�i?.� city p�/'_ <br /> C-57 Contractor ( � � 1Y/ /��_hG, Address �t�Y1n�1Ab, E, DAQ City �PeLTin)l=� Lic#tet' l���honeQ9�"�J'��J'J�QC� <br /> Consuttant/SubCntr r,�,i" , XL,,-Aeess IZ(43 1SAXXLbU—h(&ity Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING# OVER-BORE DIAMETER _ <br /> 0 W ❑ELL# PRESSURE GROUT&AA"-i <br /> ❑*OTHER GROUT SPECIFICATIONSAeMf- CQ ­Jt <br /> COMMENTS: A" a.W.+h-C <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION F <br /> d <br /> [IMONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL <br /> ,/WELL CASING DIA: Z <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE OF CASING:0 STEEL .PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:0 Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> / <br /> 0 OTHER: []OTHER: APPROX.BORING DEPTH '95 BOLTED TRAFFIC BOX OR Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify ve repared his a plication and that the work will be done i accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, all app ble Ca ornia . <br /> Signed —Title/Company �1 <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ° IIA.Gtd`i. sb"AL (.A.A-<t. <br /> WORK PLAN DATED: 11 <br /> APPLICATION ACCEPTED BY DATE SSUE 3 V AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE l <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> '570% ��.• n5-0. o J i�3� 5�3� SR#564 A3 <br /> -WAIAMP rF7 1 GTT=o 119:41 ITW)D 74TWIM Tri Clr-ni DGDRAIT FA1r`Drl4r`NAACh1T hrl!` <br />