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SAN JOAQUIN COUNTY we <br /> 2 ? 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.sigov.org/ehd UNIT IV <br /> Ql/F•pg� <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 /> Assessor's <br /> Well Location 61uo N, liwy 99 Cross Street I{4.Mvi 40,E City S$V,CI4' <br /> I Zip y�tl Parcel# OYI-O4U-3 <br /> Ownerty <br /> r A l b erg S<an.t a VINO Address S4t.3 C k"kte1 2a, City Slwl(k k Zip Phone# <br /> C-57 Contractor We011 Varc1 �rIIh10 Address SSIJ /�;wC/ Rdw% City k Vh 4N Lic#710D7 Phone 7d-374.4300 <br /> Consultant/Sub Cntr S.h'w—� Address 33)0 Camt v- Ita,k Dn. -""City CArAts, Nek Lic# Phone 00476-2064 <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSETYPF�IB�} <br /> [3 SOIL BORING# OVER-BORE DIAMETER IU 0.'?4 ) . MU-I <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Mw"I 4 Vit JAN4f , PVL"VL I 75 pct.} jt{P, <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:❑Yea ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <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 /> 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 /> Regulation an I�I/jjp�plicable California Laws. { !'1 �f g 7- <br /> SignedI II'' /.6.H Title/Company l.�'da log;)� I ]°'' t, `h�'�"dN mt,461I r,C. <br /> Print Na�ltu� Date 10/ 0� <br /> DEPARTMENT USE ONLY FILE COP Y <br /> .t A <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Amt&O A)-L 17.,E 4 S <br /> WORK PLAN DATED: 0:4 j tnA14 -+ I 1 1 <br /> APPLICATION ACCEPTED BY ()o^^C=4o DATE ISSUED I 1 i I 3 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY �� �+{._.. DATE 11 S <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3S0z 4toLm 1-+'-iT+ 1+3101K_ I SR# 55101 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5W(WEB) WELL PERMIT APP <br />