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SAN JOAQUIN COUNTY <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:wvvw.siclov,ord/ehd <br /> UNIT IV <br /> t:itY l+ <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 andlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,chapter 91115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ...._ <br /> _1...1L <br /> Assessor's <br /> Well Location vr- byr CrossStreet ✓ City i] iA`Y Zip <br /> Parcel <br /> Property ., <br /> Owner ,V;*ftr,gL Isj- >,`L .�YS?'f'&J Address )LLX61 A"4% `fI� City _ _TurC_rr :Uti, zip __f'z'y Phone# <br /> _._.._ <br /> C-57 Contractor <br /> _ ... . _. # ,0 _ /7 7 ?Iq 1-150- <br /> -)k <br /> it ;hone <br /> _ CiiY Lic <br /> Ae <br /> Consultant/Sub Cntr ? Address l _ t ... .__r' Y tt& b...city FC � rtit3<,d Lic# L5 { Phone d �S r'. <br /> __ -.. �.......__ .__... <br /> GIS Coordinates:X 12> 'o 5 Z� y ���. ?��1� Township I 1 N' r <br /> �._...._... ._..._..__._, P _ Range�i� G� Section �_5_ <br /> WORK TO BE PERFORMED: <br /> ( 9;NEW V4ELL/BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> / SOIL BORING#_1,g I,���S r, 3t?i•3, 5,�i-4` ,J.t f-Ir J'3 ❑OVER-BORE DIAMETER <br /> WELL# m_. _.. <br /> _...__�_.......... ❑PRESSURE_.GROUT.__. --_' <br /> 'OTHER __....._. GROUT SPECIFICA7 i NS <br /> COMMENTS: LI ,hid. 1.3 ! L 7 'TC' 'S 0 q n ? S o i L V M r <br /> _.. _..._..._ _.. 1's r a <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> El MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS[j MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION 0 AIR HAMMERIURIVEN CASING THICKNESS.­­_1 f:t......_.. <br /> _TYPE OF CASING:❑STEEL ClPVC ❑ OTHER <br /> ❑V%+POR 0 MUD ROTARY DEPTH OF GROUT SEAL J r,. TRENIIE TYPE TO BE USED❑AUGERS❑HOSE <br /> (�AIR SPARGE";-OZONE ( PUSH POINT(GP OR CPT. � GROUT SEAL PUi•7PED:;„Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS �lLbt <br /> ❑SOIL BORING ❑HAND AUGER �o�+;' � <br /> x'T.,,, <br /> ❑OTHER. _........ _. ❑OTHER: _ APPROX.BORING DEPTH .J L r <br /> CONDUCTOR CASING Pr2DPOSFD—_--.........`__ BOLTED TRAFFIC BOX OR [3 STOVE PIPE <br /> !i!YES,livl cpr,;,fi"'S;inny i�C:XI'fanerl cCgiM; <br /> COMMENTS: -- <br /> _.. _..._ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCRg5CHMENT 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 applicable California Laws. ;y_ <br /> Sinned _QA )a 1:. " 11 '. ns1II .,�^} TitlelCompanY Rnpn1� , {� .�. (j <br /> 13 Cs Gtit"� <br /> Print Name w 11� ulg,r-d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNCI`IV FILE,ADDRESS: /2#0 at&,-� <br /> WORK PLAN DATED: Ilav <br /> APPLICATION ACCEPTED BY DATE ISSUED q 2 <br /> ...._ __ �.._........_. � AREA <br /> TION <br /> GROUT DESTRUCTION <br /> NSP C / ' _FINAL INSPECTION BY_. _ MR <br /> _ l <br /> Dt STRUCTION INSPECTION BY DATE <br /> COMM ENTSIC ONDI TIONS: <br /> ACCOUNTING ONLY: AID# ? FAC t1 <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D 8Y DATE PERMITlSERVICE# INVOICE <br /> 3 0 sR#OOS66� <br /> C` j...._.__,_._.. WC .._._... ..._ -WAIVER ........ C57 LETTER Or'AUTIIORIZATION TO SIGN PE MI. .................__ i NCROACHMEJ DOC <br /> WELL PL WAT AUP <br />