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a"•t�. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s€gov.orq/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXP,I!3E�I YEAR I^R9M 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 /> //1t���� Assessor's <br /> Wall Locadont'46Ij. eby Cross Street Cr,(,°1tn city s���^ zip `IS03 Parcel# !33.33x. 02 <br /> Property 57D%1 %K 'v 7 13d•°3 <br /> Owner L�V4 AL Oaf-mm Address 42r' N. &P ble A City St-Jen}w. Zip a2 Phone#P joj_)) 91111,fir'} <br /> 7 <br /> C-5Contractor i Address y-- City n► ►r►e� Zi Lie if <br /> G"" Pho <br /> Consultant/Sub Cutr 4c Address 301'}1-: "&el stiI CityA( �vg uc# Phone GI!`—lI'C1-o�IoJ <br /> GIS Coordinates:X _ .Y Township t�j Range 4 Section 10 <br /> WORK TO BE PERFORMED: <br /> t9NEW WELL/BORING(CPT,GEOPROBE•HYOROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING# E7 OVER-BORE DIAMETER <br /> VVELL# WE .1 • (P11,41 r-L E]PRESSURE GROUT <br /> *OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: '2N <br /> TYPE OF WELL IN$TALLATION TYPE CONSTRUC31ON SPECIFICATIQNS r <br /> 0 MONITORING HOLLOW STEM DIA,OF BOREHOLE 1 11 El MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: 4 <br /> PbEXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Sc—#+ 4V ---TYPE OF CASING:❑STEEL W PVC C] OTHER <br /> ❑VAPOR D MUD ROTARY DEPTH OF GROUT SEAL'7•3-�-I•S ' bTREMIJ TYPE TO BE USED D AUGERS L&HOSE <br /> y W A►i.ti. <br /> 1 AIR SPAFGE%OZONE ❑PUSH POINT(GP OR(;PT)_GROUT SEAL PUMPED:1P Yes ❑Ne (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> L)SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Nr t EA,A*h,V _ <br /> O OTHER. Q OTHER: APPROX,BORING DEPTH I$.S _ K BOLTED TRAFFIC BOX OR Q STOVE PIPE <br /> tl CONW-TOR CASING PROPOSCD (it YES,Yst spectACOW4 in garment section) <br /> COMMENTS: �� NS ��� arJ,p� u.}a. crttw4,..- �rcXL, s7. S'; a{t bujc(tit1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that i havePrepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all Ili to Laws. <br /> 9 <br /> Si ned I Title/Company -k. P *z* CcT -14AU1r#P9 <br /> Print Name i7AjI! 6&C1,M- Date d <br /> DEPARTMENT USE ONLY YY <br /> 5k� � <br /> SITE MAP IN UNIT IV FILE.ADDRESS: 56,4— t _ukw <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED ARFA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> C OMMENTSICON DITION S: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Zek01 $h•00 t-}8•c.D '6Af.LiA-t 1 SR#C•*-2 <br /> 57✓ WC ✓ -WAIVER C57 LETTER OF AUTHOR TION TO SIGN PERMIT!/ ENCROACHMENT DOC <br /> EHD 29.01 1 D/2a/09 WELL PERMIT APP <br />