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pUIN <br /> oo c, SAN .JOAQUIN COUNTY � <br /> ZI ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> I <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sioov.org/ehd UNIT IV <br /> FQRN„ <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location (0100 N• H1ou �� Cross Street NgmKtt/' L4we Ci L�(IaN �j y'212 Assessor's � ' <br /> Property ��1 11 ``'' city II I Zip Parcel# 110slA ' 4444S <br /> Owner �4ItYh.J 1 ,�� Address 1176 �i C1'uv f t'r v«y C' Ovd(44% `I 10 ZU <br /> 1 t ''II dY Zip S Phone q-1u8.7S43 <br /> C-57 Contractor tr/QX VA-A �.t bilk Address O R1,,4r o4 /�11 I <br /> _T SS 2n a 1I City r4`o ��k Lic#7Id079 Phone 707-374'4)00 <br /> ConsultantJSub Cntr5�+a1"+5 L"t V?ru..r,<.kddress 3336 (4mcn,It•.•1L Qt,Rei)City (At•+tlrsA kek Lic# Phone 00-676.2064 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NJ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [I SOIL BORING# ❑OVER-BORE DIAMETER <br /> FulWELL# MW-billU. ❑PRESSURE GROUT <br /> -OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> M <br /> MONITORING HOLLOWSTEM DIA.OF BOREHOLE r ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 54 LI U TYPE OF CASING:❑STEEL &PVC O OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL C11 TREMIE TYPE TO BE USED Q AUGERS 01 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 ti Cie"M <br /> ❑OTHER: f . '" /❑OTHER: APPROX.BORING DEPTH Oy1 0 BOLTED TRAFFIC BOX OR Od STOVE PIPE <br /> COMMENTS: Cali es"at5 ilii yQQN)/tQ 510,e /11110 CPPIDuoxlR 16GPROPOSED ( YEs.list specifications in comment section) <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 /> Regulatio and 1 1 ,icable California Laws. / �(� / ,5 " <br /> Signed pp / 9 Title/Company Ge0tC,.2 ¢ / Jn gfMl LYS.✓• wt t. <br /> Print Name �l m U"Ap "4 d Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 6 t 0 o A) . I-}i,, q S-L&a1 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED 14 <br /> Z5 O1 AREA <br /> GROUT INSPECTION BY tk�Ar"ra.._ 1 I 229109 I EJ-10(LFINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY 9 rS M DATE <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3sa1 g9.0e SR# 56 411r <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC r. <br /> EHD 29-01 11/5rU7(wEB) WELL PERMIT APP <br />