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oPaus ' SAN JOAQUIN COUNTY <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT <br /> .SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �1 IVUne.(209)468-3454 Fax:(209)468-3433 Web:www.siaov.om/ehd UNIT IV 1 <br /> 17 t9ia!n1 WELL PERMIT APPLICATION <br /> r. �T <br /> N- D PERMIT EXPIRES i R FROM D <br /> Applit:atie County for a permit to construct and/or Install the work described. This.application is made In Compliance with San <br /> Joaquin Cou ter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> Assessor's <br /> Well Location 6 zoo N• H: ��k q Cross Street Eacf 6 e4;a-*__L.t. City o c kLAn Zip 175'z r - Parcel# v - ►o <br /> Props <br /> rty IL-I 150�M:C <br /> Owner frwlk FAddress Sot S- Aurae, s4- City S{+c kPc.n Zip 9 "L 01 Phone# 44b- OV33 _ <br /> C-57 Cart4rador Vow D.:11 ^y Address a a•o6 jpvcL- rrjfL Dr_ City {+ Zip-ILLI-5-- l-IC# 7 t o q e Phone9-'7'7 <br /> e o <br /> Consultant/Sub Cntr fir.►., Address %114 M w;. S+r e t�__ City Es it W 1w. tic# Phone 6 3 f" 'I tr S If <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT AtwS a t 7 8 <br /> ❑*OTHER GROUT SPECIFICATIONS w t <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: jet 4r. t <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 HAMMERIDRIVEN 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:1P Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOII.BORING ❑HAND AUGER GROUT SPECIFICATIONS Mead tG wa.v.4' Aro J 4- <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH [3 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> OONDUCTOR CASINI3 PROPOSED (s YES,Mat spedikau"in oonwnent section/ <br /> COMMENTS: tk5 vAh l 10#- 'rp�—r-re-rl rave'.; ( � <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 all.applicable California Laws. <br /> Signed V Title/Company�S �F lre•�O�i S f �G sU...+.� Z t i� f��+a 1S <br /> Print Name JuC v S C'tr Date (00(" (a <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDRESS: J ?d& W 957 <br /> WORK PLAN DATED: �T Id <br /> APPLICATION ACCEPTED BY I&AuAGp�L\ DATE ISSUED 0 AREA <br /> GROUT INSPECTION BY o FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMnTED CHECK 9 RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3�bz t(oS,oo 0111 -6 ' ! IS CI SR# 60Z+0 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC .. <br /> EHD 29-01 10128l)8 WELL PERMIT APP <br />