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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Tele hone: 209)468-3449 Fax:(209)468-3433 Web:www.siqov.orO/ehd UNIT IV <br /> k0 e. WELL PERMIT APPLICATION <br /> / =r411 -ntiiliFn? 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. Assessors <br /> n'T7� E Mralea.. MIE Cross Street IALf ke "" • T eEt- City ,�L til—_Zip <br /> 75zAZ Parcel# t'19 Zy'D 1 <br /> Well Locatio n 6 <br /> Propec c' / Sj QVMLr.r,1 Zip g�/S833 Phone#9ZS "S-734A <br /> Owner ,5i' ec � IGMn LoN►tl?� Address(. �Ilratr St- +� rte CityyM <br /> � ' �� �� ,e�OryWw6 Iwe. Address .3(o3Z QaAEC C1LC��—_ City �'Lic#�ll'1 Sf0 Phone ql(r.`S�t•ll is 9 <br /> C-57 Contractor [...'w L;c# Phond�/b 98S•ZD-Iq <br /> ConsultantlSub Cntr <br /> ►3tcc Db Address 7r�• 1 TYt YMo SurrE tlSCity �+✓. <br /> GIS Coordinates:X Y <br /> Township _ Range Section <br /> WORK TO BE PERFORMED: ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> KNEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑OVER-BORE DIAMETER <br /> SOIL 111IN1# f1S ^ IPRESSURE GROUT <br /> WELL# SVP IA Ihro L SVP-BA SVP-IN 1't1ra.+.JY. SVP-Sg �14 iotwl� ❑GROUT SPECIFICATIONS <br /> ❑-OTHER <br /> " VP-P t '1" b <br /> Ka SVP-13= !o" OHSP <br /> COMMENTS: "� ' $ OD RSA 51 ... u' b S <br /> N 0 ti <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 <br /> ❑MONITORING k HOLLOW STEM AWl L Sr1-d DIA.OF BOREHOLE rI=4 e [I MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: { <br /> TYPE OF CASING:[I STEEL PVC Q OTHER w1Nl <br /> El ❑AIR HAMMER/DRIVEN CASING THICKNESS +•9C fry AS'l-REMIE TYPE TO BE USED AUGERS Z HOSE T••jjVV <br /> Z VAPOR SVP's El MUD ROTARY DEPTH OF GROUT SEAL <br /> a�'' � ; Ito 'FY 4'R1M tC <br /> I--]AIR SPARGE/OZONE El PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:(y Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') �fOVk <br /> IX <br /> ttU GtOUE t� pcsa'` • CRwttNE S°10 bLK�I� <br /> SOIL BORINGA$g'1 IR HAND AUGER SVP'A GROUT SPECIFICATIONS CtrYt : <br /> APPROX.BORING DEPTH S 20 dJjKBOLTED TRAFFIC BOX me <br /> [3 STOVE PIPE <br /> ❑OTHER: [I OTHER: COND CTOR CASING PROPOSE if YES,list specifications in wmment sedi�) <br /> COMMENTS: '• <br /> �J <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap Ica Is a1i a a S. r (� <br /> Title/Company ENt �+J6 �Ufct-�.sT 'fSi�z—'Tb,(s <br /> Sign <br /> Date <br /> Print Name �fi1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: N <br /> -1 r' - _A,.v <br /> WORK PLAN DATED: I I it'0 Olt y <br /> DATE ISSUED 111,3167 AREA 7 <br /> APPLICATION ACCEPTED By <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY L DATE ZZ <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# <br /> RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3Sa l I 9 �$SS`f t �3 3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-Di 1115W(WEB) <br />