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-. -� SAN .IOAQUIN COUNTY <br /> PED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> 4t i <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 /> r,� <br /> Assessors <br /> Well Location )dq rf S.ban So SE P4ross Street (lkoy}'(Telt} LinN Q& City Zip Parcel# <br /> Property <br /> Owner ILJr>Gil A 6 arIJ K•S. Sib/a_Address 113 Lo.S M I cf i1 cfl S k/A City a L ck_,,<-A Zip'?I�W/ Phone#(510) 531 - 2-W 7 <br /> C-57 Contractor Address Z-� I v� "t7 SL <br /> , City Jpd �-LC Lic#$02Phone/5 <br /> Consultant/Sub Cntr 0A [ Address)� � 33 <br /> L r —g _Phone(S UC)) )�oI((OD y '-7Z�1 jZZ <br /> GISCoordlnates:X Y 7 <br /> /,Township T z-S Range�_F Section _ <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> j$SOIL BORING# (13 OVER-BORE DIAMETER <br /> j]WELL# — ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: CK <br /> V <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE S „ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIAL- <br /> EXTRACTION <br /> IAEXTRACTION ❑AIR HAMMERfDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL T TREMIE TYPE TO BE USED❑AUGERS HOSE <br /> ❑AIR SPARGEJOZONE PUSH POINT(GP OR CPT)-Lf GROUT SEAL PUMPED:❑Yes XNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS Njc-d+ <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ON OR CASING PROPO ED (AYES,Ilet specAlceGane in comment ron) <br /> COMMENTS: <br /> rrt 6Y" RQ, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT P MITS �J} <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and V <br /> Regulatlo�ns i! all applicable Calffo Ia Laws. 1 /� <br /> Signed Title/Company <br /> PrintName i��'�, �y�G'C�j Date ! ` G! <br /> A DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / v y/ W, <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED '0"02AREA O6W <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT D <br /> EHO 29-01 11/5107(WEB) WE0 PERMIT APP <br />