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D <br /> � .SAN JOAQUIN CiOUNT �� VE® <br /> ENVIRONMENTAL HEALTH DEP SITE <br /> 600 East Main Street, Stockton, CA 95202- 9 � 20�� MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:W�^.�'��vC.or ehd lJ -�-� m K UNIT IV <br /> WELL PERMIT APPLICAI�I RERRE <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 D vel ment Title,chapter 9-1115.3 and the Standards,of San JQaquin Goun nvironmental Health Department. <br /> Gng T7 oTtit/ Ice<T tAJ on7'': � ^n� 1 r;5 t` � lay Assessofs <br /> Well Location Z f Cross Street �-f--f " aw City 57n"L rm Zip`0)571 GI b Parcel# 6Z � <br /> Property G ``}5"G 26L1 �- 111" � <br /> Owner -,DjAddress I$I Ei—�=-k(e E e I tf city 5rnr fr.I Zip O S�Phone tf <br /> C•57 Contractor G- Address �9 Ssti Clr 5 ����! City R �t �� Zip ZSZ Lic# bS P ode�6 �Q <br /> n Sc er1n fcn� y <br /> ConsuRant/Sub Cntr C-0^14opf-F- ra Address lRr F(o.nlr Wt r/Ci• Stt elty t�41 Lic# Phone Z -0S/6 <br /> GIS Coordinates:X i R P 1•Y .2(612-6 Z.77 ,Township I, / Ran ge CbE�Section I�+�}�+3/ <br /> WORK TO BED: <br /> J�CQ �tlaCQ. TlV J� 5 <br /> ❑NEW WELL=PT, EOPROB YOROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> E3 SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ,�,�I) /L GROUT SPECIFICATIONS <br /> �'`OTHE G ,�/1�T-^^5t 1r' `n, ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: AT- lit <br /> RP 111 , t CoT if 5 All (- 3l�' Aet— bP jow sk��ce <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA4?--SOI TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE {PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30•) <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �eLVbs.f/)v2- <br /> 0 OTHER: 0 OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list sxair ons in mnvnenl se w) <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 /> Regulations,and II applicable California Laws. <br /> Signed of— .�/C.�ZL Title/Company <br /> Print Name U/ YI // c..o d Date 1 <br /> I � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7-!;a--> Ili giV+l .-12('v11 /C__ <br /> WORK PLAN DATED: O 6 <br /> APPLICATION ACCEPTED BY DATE ISSUED•q. tz-dt 12 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <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 /> Lq,70' ?"t-cam LZok rt(IJ SR#S A <br /> C-57'�' WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10128/09 WELL PERMIT.APP <br />