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SAN JOAQUIN COUNTY � � <br /> ENVIRONMENTAL HEALTH DEPARTC-, � Ef VIL D) SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www42@v.gr /e <br /> t� 08 UNIT IV <br /> WELL PERMIT APPLICATIOkbiRU,' AJE-Air HEkITH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' S <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 /> n rQ, V +e,PA Assessor's���1 ��� I <br /> Well Location r�3 7�J�G VuC'd "is Cross Street f� 1 City (/tC(MC 1✓r� Zip Parcel# rte <br /> Property F8 Mfr!/ Po �x a�ios� y 0414 p 911623 s' 3 <br /> Owner LL77 V Address �" � Cit Zi Q Phone# ��/�+��� <br /> C-57 Contractor P/-t'e/s� Address 03&5 i9"�1 City C Itl Zip /f��Lic# �3�38 / Phone <br /> �/� V L <br /> Consultant/Sub Cntr r/ ej&rPlxel- Address -08,:p City City 1,) 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-) �9 DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# XPRESSURE GROUT <br /> ❑'OTHER ,( / GROUT SPECIFICATIONS eei c 1fe; <br /> Q <br /> COMMENTS: / -e ZOP41 e /lry�� <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 /> IN <br /> OTHER: ''e4M7 ❑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 Californi aws. <br /> Signed Title/Company <br /> Print Name F,k ve<3I� ti/ t��'t Date <br /> Z DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: TbC so ! 10AU'y1�1 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED Z AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY ` DATE <br /> COMMENTS/CONDITIONS: 71 6YL� ✓ � /L� I.el_I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> a2�PZ bJ �l1- /72 SR# 603 Q7 <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 />