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•� e <br /> SAN JOAQUIN COUNTY Noe <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.siaov.oro/ehd UNIT IV <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 4IDo N. (4WH 99 Cross street N`rt"t A.er Assessor's <br /> Property �'t City S1oLkli,,% Zip c(yll� Parcel# 087-o4©-J4 <br /> Owner Aibeq� SLAny1aV:A0 Address S4G3 Ct11s. k-4 Rats( Ci SI LJC4 <br /> �y VA+.et ✓!I 1 City Zip Phone# <br /> C-57 Contractor In Address S50 haute A..4 h <br /> 1 I' CitYQO V,S J.S Lic#7ID07 Phone )0 7- 374-4)00 <br /> ConsultanVSub Cnlr S Mkk1 Nv�.errlh Adlotclressj�)0 CaKW6,&-1( D,r, tt5 City cti,rife6N 1^6AAllil #9S�SZ phone 53U-671x- 064 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> CK NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) S CTION(CHOOSE TYPE BE119 <br /> ❑SOIL BORING# O -BORE DIAMETER M6l-I, X dCuw el V <br /> WELL At MW-I Rt r1U-iRl 7ww 30.,MW u�M+v I ,bwUA-iRI16``nl ❑ ESS GROUT <br /> LJ'OTHER ROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0HOLLOW STEM DIA.OF BOREHOLE S II ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z" <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SL4 4e TYPE OF CASING:❑STEEL gJ PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL �ZI V 9�-I TREMIE TYPE TO BE USED❑AUGERS OLHOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:•R Yes ❑I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS "..N.r CP.,»:.t1I 9 M uAM <br /> t / <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Y5 d r I oV 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASINO PROPOSED An R YES,list spetlbrations M mmment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a�Jf�/�a I applicable California Laws. r/,, / !' _ <br /> Signed4/0t`L,,'i' Title/Company `fo(OQ ASFl"0. Al 4�'1+1�/ , <br /> Print Name rQ#&. a Iky Dale 7/IL 1�0b <br /> DEPARTMENT USE ONLY FILE COP Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Mno tU• Fh.i... of "11. C'IU c-� <br /> , f ' <br /> WORK PLAN DATED: O - Lt 60 k <br /> APPLICATION ACCEPTED BY ( ,�,o•e— DATE ISSUED /O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE Is teat <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CRECK RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 35v 1 to I' oma. SR# 15-5 2 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHO 2&01 1115g71wEB) WELL PERMIT APP <br />