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oA`•�u•'•" c �� SAN JOAQUIN COUNTY 'ft4 <br /> ?� ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> j�1„rim ne: (209)468-3454 Fax:(209)468-3433 Web:www.sidov.org/ehd UNIT IV <br /> �J 11 WELL PERMIT APPLICATION <br /> +:v17ILOG <br /> EF <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> }-�AppgicatL,c i o iri County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Cou �Iaa ter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location '9 7-00 N• R;$kAvT Cross Street e.%+- fro na,ano t+i• City y+u t-1k{P%_\ Zip 9Sy i?_ Parcel# UES - ?10 <br /> Property ¢aV t3c.J1:E+�0 — <br /> Owner_ 1�rw+I4 1'a.+t Address 3ol S• Au ro,N 5� City Zip 95zo3 Phone# W b b - O yY <br /> '169-17 o o <br /> C-57 Contractor V 4 W E)r 1l ^”{ _ Address 3 Bole D v c L Gre a lc_ _A,-.__ City Sero c —+0c Zip 79 2-?S Lie# 7 i° p a`f Phone <br /> ConsultantlSub Cntir n,�.+ a ;e!b Address %'714 M&-., S+^t a f- City ES c a�w. Lie# Phone ff 3 5' -eT Ir Ir K <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") DESTRUCTION(CHOOSE TYE @40W) YW-I <br /> ❑SOIL BORING# E?!�OVER-BORE DIAMETERw <br /> ❑WELL# PRESSURE GROUT MW 5 V I gs.17 a <br /> ❑*OTHER GROUT SPECIFICATIONS 1$Lrt4 _fw <br /> ❑EXPLOSIVES DETONATING CARD <br /> +vow-lzlsuW7���a�"UI w16.}`�g <br /> COMMENTS: See w f4r'CL%&d a'4t101G �— '---a 4-eft—, .-,I of MLA)-13G, uk�d <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DSA.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 SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:5@ Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS t4kcO- Ct.+.�... r0.+ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Vo. ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Aell5 vA tlsxa�o e rnc5v+l� ro� ;. r �,:II l02 .a x4 b ove-d"'if `^ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 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 \J Title/Company Sfa F t­ea i S+ C e)�-,l -ze re <br /> Print Name y t bot A t z _ Date (01I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 162-00 N' 7 <br /> WORK PLAN DATED: 4 /b <br /> APPLICATION ACCEPTED BY DATE ISSUED 4 1, -11_0 AREA <br /> GROUT INSPECTION BY C S FINAL INSPECTION BY / DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> 3�`oz _$ yoS,00 0jcjc77� 618110 SR# �,OZ}D <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 10128/09 WELL PERMIT APP <br />