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SAN JOAQUIN COUNTY <br /> SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ,. P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.si-ov.org/ehd UNIT IV <br /> �� <br /> 4\4' rt <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 /> a(S?a4/>"rf�Jt/c� 8uevtc V{�a ROS Assessor's <br /> Well Locatior>Camuvt�l,�IGSh tfa}cl ery�„ Street��7�4M 1/r�,P� t? City �le✓1'�P�IfiS zip �y5 aa'7/- Parcel#023- 0!!9 -b/ <br /> 90 <br /> owPronert� t 13AYAWCA 015t. RX-A tress 9000 C - PIC-Pe FGA City_ile., Zip_15j6�410 Phone# `763 -51,a I <br /> C-57 Contractor Pc�X�l Qfi1011 Address3g03 Grnui�Qtt A/C City 9o�llf1 Lic#�Zk 00Phol e`673q-qd00 <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') ;n DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �t <br /> /� u <br /> ,MONITORING [I HOLLOW STEM DIA.OF BOREHOLE �(c/�II ❑MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA. <br /> [I EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS, TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR MUD ROTARY DEPTH OF GROUT SEAL75'3+S 6 TREMIE TYPE TO BE USEDJjLAUGERS❑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 b El HAND AUGER GROUT SPECIFICATIONS Celle r)l_ b ifilton t fe y grout 6G4 5taatc1, <br /> OTHER: Pi eZ-011 CYS❑OTHER: APPROX.BORING DEPTH 100, 60(1 30' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1� CO DUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: U �a(Io') 75 Sea.i , 13-,3 16 0'-j 91.Sfaj . 13-[2 l 6ea I <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, d all cable lifornia Laws. <br /> Signed r Title/Company a 1 r1 � -PC Exiora.11-�� <br /> cn <br /> Print Name �(�I'1 I'1 e P l e m 1 rIq It Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> a / <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY '''�' DATE ISSUED ' ( ) AREATi <br /> GROUT INSPECTION BY FINAL INSPECT ON BY DATE <br /> DESTRUCTION INSPECTION BY DATE / <br /> COMMENTS/CONDITIONS: 4aL. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> JP/ b SR# pp L41 7 <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 />