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�o..�_„ •�o SAN JOAQUIN COUNTY <br /> r ' ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> • (0 :< <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sjoov.oro/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 /> Well Location 5�lsW W�CF Cross Street l-�nL4 h City 5 101k1"Dn Zip If4OS Par el#x133 . Z60- IS <br /> Property (µ.teff4-r@ A'{o.Avs OL iters <br /> Owner L wo T•A I Address C <br /> 01 W.WOW 5-re SOCity GWgVd% Zip 9,tJ-0 3 Phone#CA09J 1?12 -?L Z t <br /> CS7 Contractor G ,ra6f.D M Address I b Haj,_ City 1,AC1r Zip!9-633Lic#ytrl L.f Phone <br /> Consultant/SubCntr A&At . Address 30 I- (50(< City R e G►4OJti Lic# Phone <br /> GIS Coordinates:X Y Township N Range (O L� Section 10 <br /> WORK TO BE PERFORMED: <br /> ' NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORINGS &I O_Pe.i-Ir ❑OVER-BORE DIAMETER <br /> ®WELL# RtPRESSURE GROUT S ✓ <br /> [9-OTHER e.tf be /lit" GROUT SPECIFICATIONS <br /> bOc:w ks ❑EXPLOSIVES DETONATING CARD (VEA A= <br /> COMMENTS: TVWA 'batt w:kt )0a &:re,rM Q.e�1► WICt7 P1*5 1ANOwrLeal IAQM Lim( �G�On G� t�`TGIJ 1 <br /> la <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE r <br /> �.� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS / TYPE OF CASING:❑STEEL ❑PVC to OTHER (S 1" <br /> • ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL L�f TREMIE TYPE TO BE USED❑AUGERS 12 HOSE <br /> E)AIR SPARGE/OZONE Q?PUSH POINT(GP OR CPT)�e�GROUT SEAL PUMPED:®Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING I]HAND AUGER GROUT SPECIFICATIONS dto �►w.1t 1p..i�t�..! G.N,.,.� sr—, <br /> POTHER: CYT -tAVOST 1'+a OTHER: APPROX.BORING DEPTH "bO l ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CAS1ItG PROPOSED (if YES.Net specifications in comment section) <br /> COMMENTS: N`dk WtAl$ 4v �t�QtV3.& 4kk6�'M e.WPW►M <br /> 7 <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 allIcableGalit'/rrnla _Laws. <br /> Signed Title/Company rA. ^,tre' <br /> Print Name ZAN fC-% BSN W— Date 611/0 <br /> DEPARTMENT USE ONLY /� <br /> SITE MAP IN UNIT IV FILE,A RESS: 5oAte <br /> uTti %MME >PAgift EL Rt.,Od ISOR. J!C1 1-4 . <br /> WORK PLAN DATED: 3 'O <br /> APPLICATION ACCEPTED BY `AN AAACC4 L DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 2.gbSr 44S-1.or, wjt61(-)- (Ir 8 tU l0 SR# 60$63 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION I SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />