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SAN JOAQUIN COUNTY <br /> z ? ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> a <br /> y'• - 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ' <br /> Telephone: 209 468-3454 Fax: 209 468-3433 Web:www.si4ov.orgLE hd <br /> c�a-.-...:::..•;P A ( ) ( ) UNIT IV <br /> �fFoaN <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �M�q <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 co/�� iN do <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departmenl <br /> Well Location ?`t 0o E. N�rd� PY� Cross Street V. 1^otdtr �N�t Av-. City S'(-o&��,tA— Zip °I yZ d S P �- <br /> l� Q�� <br /> Property �4TIP� <br /> Owner cW.g^ QroV.,k-1 e5 Lt G Address Ad 13o-f- ttto Cityme.ufwf- QPrx.IjZip 91(rbZ Phone# <br /> C-57 Contractor V 4r UJ 1) Address 7 Y6te Pvtk 6ve2 F- pr, City S+o ofe-•j-rnr, Zip q5-1(5' Lic# Phone <br /> Consultant/SubCntr lrreo^el ZGrb Address 1714 City Lic# Phone SSR �°TB7s"S� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# N OVER-BORE DIAMETER 9"' (MWI <br /> ❑WELL# [ PRESSURE GROUT Awl. AA WN �4 w S' <br /> ❑'OTHER GROUT SPECIFICATIONS fllj 1 <br /> ❑EXPLOSIVES DETONATING CARD IN1C/�1T <br /> COMMENTS: SnacFed SII fes,/ ,,,e(lj ato tti C�fZpl-+� <br /> S �-o �/ a vt�ef r;I IC d, Nba c- tf.�eCS v.�t_ Ch✓u✓{�/ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 5MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Cl MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED[]AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specificalions in comment section) <br /> COMMENTS: <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 allapplicableCalifornia Laws. <br /> Signed Title/Company S+c4 lFf U'eo lvy�Irro-nil 7C-0 A,"1% `S <br /> Print Name N it Date r/.$7- <br /> DEPARTMENT <br /> /,sDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7-9 00 l 0Ltn.,� <br /> WORK PLAN DATED: l�'I.( __- <br /> APPLICATION ACCEPTED BY U /An^'CCA DATE ISSUED s ! 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 /> z9o� s;cr2z �� ala• oG z�L�t �� �-�sj't R# 6Z`I56 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 10/28/09 �, WELL PERMIT APP <br />