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`s SAN JOAQUIN COUNTY �5•.c I � ENVIRONMENTAL HEALTH DEPARTMENT SITE �f 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.Sigov.org/ehd UNIT IV WELL PERMIT APPLICATION j NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 t Joaquin County Development Title apter 9-1115.3 and the Standards of Sa Joaquin County Environmental Health Department. � r 4� W- q Assessor's 0-.-f7 Well Location 21100 5' `fid'N Cros street f141�We � City �raC Zip _)d c��Parcel'# ROW Property, a4n CP (' �� l$ o E. ��I �(,� Cit ,TloC ton Zi _S G��Phone#Z� y6B`�F00 Owner C i� S`�1L Address Y P C-57 Contractor -9Rk�i vld Address �-� N• CI �S sem• City�� Lic# D2-3 Phone�G) 1,6K Consultant/Sub Cntr �R�� p Address 1000 1%QaA( `D-5sJ. �t n�V City Lic# _Phone�510� 4�c h z7 13Z GIS Coordinates:X T•'f D Y 2-4• Township 1 Range u Section l WORK TO BE PERFORMED: ❑NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) }SOIL BORING# t PjMa r7 0 (6) ❑OVER-BORE DIAMETER ❑WELL# ❑PRESSURE GROUT ❑'OTHER GROUT SPECIFICATIONS COMMENTS: d TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIAWA- ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL I L)hL PP-AtITREMIE TYPE TO BE USED❑AUGERS[',HOSE ❑AIR SPARGE/OZONE CpPUSH POINT(GP OR CPT)CL GROUT SEAL PUMPED:❑Yes'�,}-,N, (Nl.- o (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') .SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS I eoz e n 6WL ,OTHER:I 'V C OTHER: APPROX.BORING DEPTH 7 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CAW P OPOSED (irYE3,Ilst spedfications h comment seetion) COMMENTS: l Z1 r 1q -i VL�j NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENTPERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and all app Ica Calif rnia Laws. ? 1 /I A +�- Signed Title/Company Pio;eC� G�O�-IogrOD7 / J7P.EC Print Name A^ I C Data J/,2 o log DEPARTMENT USE ONLY at//e(,llac,6 pdd SITE MAP 1N UNIT IV FILE,ADDRESS: / WORK.PLAN DATED: tj G Z 00 2* APPLICATION ACCEPTED BY DATE ISSUED 5'-0/9 AREA D GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE 29 o I CLeCX5 #OS 5l C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT of5W�T DOC /J„09��W�PERMITAPP EHD 29-01 1115/07(WEB) r(/��