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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:vwvw.si4ov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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. 0.13- 156- <br /> `/ ,f ! q Assessor's J�-O <br /> "V11 �I cation YZ 14/ _S• l Gv [ ALV'j(�--Ci R5d�� Parcel# 2 3-610-67 7 <br /> e �� Cross Street ty Q,YYLP.n�s Zip <br /> Property '1,,, (� -� //11������ nn � -t��� (� l�, �1n _ t- <br /> Owner ist. ,Vl'Nud �f5�.�o�fe5 AddressM6 1.A IQA CI Ve M City .pL.y� n'V Zip 1(y -fir) Phon� 76033 J la j <br /> C-57 Contractor P�IV A II ort Address3 00 3 Onci 1(M I kye City OCK l4 Lic#99 1 30 Pho"" q34-452-04)e <br /> Consultant/Sub Cntr Address City Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) CXDESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ®MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE II <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ElEXTRACTION Elp <br /> AIR HAMMER/DRIVEN CASING THICKNESS OCA TYPE OF CASING:❑STEEL ®-PVC ❑ OTHER <br /> ❑VAPOR T.MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING [I +Qy HAND AUGER GROUT SPECIFICATIONS('P�Y►ev� lx,+v�vll ties QI Dc,��6A s tC11l <br /> If OTHER:1`e_10M1'i 5 ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> �^ !!__ CONDPICTOR CASING PROPOSED (if YES,list specifications in comment on) <br /> COMMENTS:J-dba*,Arn jq ?SVCYOfy lit V", IU4A _WjeW le_ o e--, �C - �3 D L77 r <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, nd all applicable California Laws. y, <br /> Signed 77-1-4-- Title/Company I I I f r(�jV J C l m <br /> Print Name SD n h e, Piom I na Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1;p- <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED l I( i /' AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE // II- 2,001 4)-rl- ,?zl_ <br /> kp� <br /> COMMENTS/CONDITIONS: N_ I 4.yAlip, 7 l OC Z 1,3i�) <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2M1 11/5/07(WEB) WELL PERMIT APP <br />