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P��rEN <br /> SAN .JOAQUIN COUNTY <br /> k&5" <br /> ENVIRONMENTAL HEALTH DEPARTMEN �� DE�'fP�r``ET,T SITE <br /> .! 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.ort/ehd UNIT IV <br /> t ` <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES,1 YEAR FROM DATE ISSUED <br /> Application is hemby 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Location s+U. �� Cross Street _NIA - 1o5es4-;s Assessor's <br /> Pro H!eLftme,�1yG City Ve .� �.�i� �7 7,;t7rkZip Parcel# QV0 7 <br /> Pro <br /> por3y �� r' <br /> Own or �b}tTM t�'14., Address bA( (I�Ik,Pne �� � City �cl4j, Zip 5 O Phone* <br /> C-57 Contractor ,Ighc j 2ti llj�t°' dr'd�ess 5 rErut r - — City_Pus V114 Uc#7/0079 phoneC.2o -3 0 <br /> ConsultantlSub Gnsr I`ll Address City LIc# Phone <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLJBORING(CPT,GEOPROSE,HYDROPUNCH,HAND•AUGER,OTHER-) L&DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORINGp OVER-BORE DIAMETER <br /> ❑WELL# aPRESSURE GROUT Zr`X7o' +L'e mut ✓ Zyc <br /> a' 3rb <br /> ❑*OTHER 1 i <br /> f���1i1� ele{ nGROUT SPECIFICATIONS �� Sac I <br /> COMMENTS:(�j�A�w1GreJ �nt_- s n. rt� �l"�Zi2(�� kJt'II Gl/G Y(!`If' IMG�ygpe iG. yl[✓2Lk7C3� e�I <br /> LYPE OF JOLELL iNSTALLATIQN,TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE R•, ❑MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DlA Z" <br /> O EXTRACTION ❑AIR HAMMERIORIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ' <br /> ❑VAPOR E]MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED Q AUGERS El HOSE <br /> Q AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED.$Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER APPROX.BORING DEPTH ❑BOLTED TRAFFIC eOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PiROP03£D Of YES,Igt spWficattons In omWrMM section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS won <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby csrtNy that I have prepared thls application and that the work will be done I accordance with San Joaquin County Ordinances,Rules <br /> Regulations,and all applipabie Calftrnla Laws. r e s <br /> Signed l <br /> 9 Tltle/company_ Pres;,L Jf �Iw <br /> Print Name _ r tq!;­� �/ !Zao Cl =- <br /> Data 3 2 0 CO- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 59 Lf 2 /V - <br /> WORK PLAN DATED: A- <br /> APPLICATION ACCEPTED BY Ge.. DATE ISSUED 2 3 O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 3 2 3 D9 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDMONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMrrIBERVICE# INVOICE <br /> 3sa 60. v 27 t to �� 3 a SR# .5-( I <br /> C-37 WC .WAIVER lay <br /> C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> C"D Zs-ai t�iS07(WEet <br /> WELL PERMIT APP <br /> a <br />