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SAN JOAQUIN COUNTY e�A ENVIRONMENTAL HEALTH DEPARTMENT SITE I" 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sioov.org/ehd UNIT IV WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 595b AhI4W 95 Assessors Well Location � Cross Street f(4w„nU �"'� City SFel:k r4U Zip `��IL Parcel# 60-01U•u e( Property 64A fI,K 1 Jt"OI.IC�M Zi 9S11L Phone# Owner Rr./d Abed 4„d FwV' D;,b Address W4A 191 City p C-57 Contractor 1Ju[/dl//u 1 pr,�l+�'11y Address %D Al"t� /coa�&l� (� I�,,,_city 2}p I/,SIA Lic#710079 Phone 707-374"4300 Consultant/Sub Cntr��s �K�' Address 3330 �teCA Pw•k L kV)Cily A Pkek 1,w,x9_C6!j1 Phone S30-67(.10b4 GIS Coordinates:X ,Y ,Township Range Section WORK TO BE PERFORMED: 6Q NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ❑OVER-BORE DIAMETER NWELL# DnW-I R ElPRESSURE GROUT *OTHER GROUT SPECIFICATIONS COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS s JAMONITORING 2Q HOLLOW STEM DIA.OF BOREHOLE �II ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:z ❑EXTRACTION 1-1 AIR HAMMkER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL,k PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Z I TREMIE TYPE TO BE USED C9 AUGERS X1 HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:W Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS K&I CPN^{."l- ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ()O d'Q BOLTED TRAFFIC BOX OR ❑STOVE PIPE /II 'n T ONDUCTOR CASING PROPOSED (if YES,list spsctri ions In mmment section) COMMENTS DM If-31pp ✓. bC (Vrl.ll'fu yt,[(y- M�-9 NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR IN PECTIONS 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 Regulations; anddaalll plicable California Laws. �,.,p Signed//✓"//I� Ir/,r/N(� IIeI Title/Company "'�O�o�t`�f /�/�'�1�) `I^y',�N L Print Name / 11ah I,1n4LLMg Dale 111,q Ul DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: L l ow � GGl S^I�j .J COPY WORK PLAN DATED; aTI-R-W W.�^d _F APPLICATION ACCEPTED BY _Lk, .uA C if i DATE ISSUED Z, D AREA GROUT INSPECTION BY FINAL INSPECTION BY U.+ r DATE l l O�,' DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# 1PE CODES FEE INFO AMT REMITTED CHECK If RECV'D BY DATE PERMIT/SERVICE# INVOICE 35-0 l 4tJ'r 1 -9,1w &t- SR#Sr�Sq C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 7 111/5W(WEB) WELL PERMIT APP