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. SAN JOAQUIN COUNTY 5EC�� �UILL; <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> f .?. ;'d"'` 600 East Main Street, Stockton, CA 95202-30?QPR, ` j 2008 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.sogov.org/ehd UNIT IV <br /> ENVIRO,�jrocf\1T HiPA I <br /> WELL PERMIT APPLICATION DERP01T/SERVICES <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 /> /,old #a4 le?- city /1 Assessor's <br /> /aCAne�Rd�Corc�i� Cross Street W1�6i'N1 f�� 6�3 <br /> Well Location Zip Parcel# h� <br /> Property <br /> Owner SKS kAAerpPiSeS Address /P0 V y 130!!1l city .146, Zip p 9P-717 <br /> D Phone# <br /> C-57 Contractor //(C!��$///)'0/� /l ress ��`i i/��/ City 1 �/�(N Zip 9s� Lic# to I/W l Phone <br /> Consultant/Sub Cntr /(lfla/;e Ali!! Address 0�,rd5 Ayl1 `e- 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# OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> ❑'OTHER Q / ,y /7 GROUT SPECIFICATIONS « P�lIK/ /w <br /> COMMENTS: /l CYOkwe4e r //" 74 / <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑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 ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑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 that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California L ws. <br /> Signed Title/Company <br /> Print Name /Q(!! PGN Date y a7 D <br /> 40(so­ <br /> DEPART NT USE ONLY <br /> SITE MAP IN UNIT IV FILE,, D SS: (,&- <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED q11 r AREA Z <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY ( DATE <br /> d'�- .Q <br /> COMMENTS/CONDITIONS: % S6', >. `n a,-4";;fla •' <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> yo7 60" 66 " 13��1v � �/ z 6Y SR# )-39411 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />