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'"`` SAN JOAQUIN COUNTY <br /> 4 <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:www.sigov.orq/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. <br /> Assessor's <br /> Well Locations o► Card k6a4 Cross Street lWV 12 City Uem&)tS Zip Parcel# 0a3- l Lto-o8 <br /> Property �7 �," / c <br /> Owner �_0Q F3t'0CC-h(C 1IOn6 Address Yl� '1vX tp�. City�lernL�JltS ZipQ,5)y )-7 Phone# <br /> C-57 Contractor P ^X Orafia Address3823 GncltntlG�i )We City �O�loin Lic#9$5k3�hone916q34-y)�00 <br /> Consultant/Sub Cntr N 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') DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# 71 OVER-BORE DIAMETER <br /> ❑ WELL# PRESSURE GROUT <br /> F]*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �I <br /> 'MONITORING ❑ HOLLOW STEM DIA.OF BOREHOLE �,❑ MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA: <br /> ❑ EXTRACTION r_1 AIR HAMMER/DRIVEN CASING THICKNESS SGA '40 TYPE OF CASING:❑STEEL 19 PVC ❑ OTHER <br /> �''1 <br /> F-1 VAPOR AUD ROTARY DEPTH OF GROUT SEAI�JtST1 <br /> _TREMIE TYPE TO BE USED.d 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 ❑ HAND AUGER GROUT SPECIFICATIONSCY..VKeri t be*1fDH t 4r_ Q►'nUt (CA S1{-QV dal_l <br /> BOTHER:1 / <br /> ❑OTHER: APPROX.BORING DEPTH ` 0/ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ONDUCJOR CASOG PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ��NO �15_SeA�, B'�O /q �o1S /D Al-al <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, dal applicable California S. ,A ,' �y, ` <br /> Signed ['� Title/Company Pri I Arra/6fo is+/�IGW qer — �G Explora un <br /> Print Name So n n ei Rem l✓ a Date (A <br /> CDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � � ,- ` J -QA r'' -` <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED !%'� AREA O <br /> GROUT INSPECTION BY FINAL INS ECT N BY DATE <br /> DESTRUCTION INSPECTION BY {� r DATE <br /> COMMENTS/CONDITIONS: S!a J� �l Q- f� n j (A . 1/, ?' ) ;_;o %1c` <br /> n &,Uv, u�d f <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> S R# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />