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w <br /> SAN JOAQUiK COUNT` <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_siixo_y orp%ehd _ UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> of /,_ r� -��• _;i +�,=-' <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. iihis {� c�tpq�,�S 2 �compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Ha •DetaEt int: <br /> � I ` Assessor's <br /> Well Location f. �'S Cross Street IV CC-A� i � City t�-C d I zip�52�p Parcel# OY31��OS <br /> Property ` t1 q s220 33(1- V YO 2 <br /> Owner L r i t rjS1�d/ Address �+ �1� Y3 City E ,,-,;r :� _ Zip Phone# / <br /> C-57 Contractor V f�`,r't/� i fl&t• Address pc 9 c �,+.�}�' ` City 4L^C Cl ( Lic#C -� Phone 3� 1"14 <br /> Consultant/Sub Cntr `�� Address t / ``��^v Gni- { City U>—"# Phone d i <br /> GIS Coordinates:X `f 13 2 + ,Y 225(_-' T'-(5, 56- ,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# ❑OVER-BORE DIAMETER <br /> ❑WELL# M'(1'0 i Z�/wW W EW l ®PRESSURE GROUT C' <br /> ❑*OTHER �f !!'' GROUTr SPECIFICATIONS <br /> COMMENTS: `4t 1i rl r j Gill(r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 301) <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 specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <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 <br /> Regulation <br /> applicable aliforr is Laws. / f� }� / f <br /> ,/(-. �6 '`' IRCr Title/Company /� IXO`rel` !•t°i , <br /> gP ,/ <br /> Signed /` � ./({J L —� <br /> Print Name `TIC 4'� w int k_ Date <br /> ! / �D�E�P�A,,QRTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3� L66"-l.,' <br /> WORK PLAN DATED: 3 t, • zo _ p <br /> APPLICATION ACCEPTED BY e DATE ISSUED AREA�� <br /> GROUT INSPECTION BY FINAL INSPECTIO BY DATE <br /> DESTRUCTION INSPECTION BY /J DATE <br /> COMMENTS/CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 1610 SR# Oc5­1, 7 , <br /> C757 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 11/5/07(WEB) <br />