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SAN JOAQUIN COUNTY <br /> COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT 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 /> '..1��FONia <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 9-111 3 and the Standards of San Joaquin County Environmental Health Department. <br /> Fv-f ' e� Tra-cy krrn Dv, p Assessor's r� <br /> Well Location 1,Y 1 Lir "fid s Street Purl Z City T- Zip /5-3 0 Parcel# <br /> Pro � , ` <br /> Owner I It L(71i1N� aYtf'lr' Address <7(u fit. E City Zip J'_�7(o Phone# (Z0) Y, 3li-33,(c <br /> C-57 Contractor IZ�r �, c c Address ??O N•Fits 05L. City GJnVd ticz nd Lic# CZZ Phone( 3C) (oL4'�zyzy <br /> Consultant/Sub Cntr.isA\C 1� Address ILW c �,'t City Q���� Lic#�_Phone(SIC) gldc 713 Z-_GIs Coordinates:X :34D Y —1211-50-D Township Range Section �_ <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROSE HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ,SOIL BORING# "Ac 1�J" '�nG ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑•OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 1�if" <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER _ JJ" <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEALT�aCh TREMIE TYPE TO BE USED[I AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes jKNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ,c' E t T 1 Eco�- <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSID (d YES,lisl"cdncauons in mmmenl section) ` <br /> CommENTS:�Tt�.'D[T/ � Or 11✓ 11 u7I� <br /> Lt. <br /> m�l7��AV I-1�rA(�A[ �.t-[t�'(*L Y1dCv�2SC�' d r�DltnC CatVi (1°111c�L� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMIIS <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 /> Regulatlons,a II applicable Callfor, a Laws. c� <br /> Signed Title/Company LaF,G I CQI SF��C <br /> Print Name Date 1 /02 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: PzryI • <br /> K PLAN DATED:— <br /> APPLICATION CAT O ACCEPTED BY a DATE ISSUED �'��0 r AREA 4T <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 /> C AQ <br /> 2 Z-17-01 SR#Oy <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT tf ENCROACHMENT DOC <br /> EH029-01 1115/07(WEB) WELL PERMIT APP <br />