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SAN JOAQUIN COUNTY <br /> ECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 FEET 2 2 2011MITIGATION <br /> Telephone: (209)468-3449 Fax: (209) 468-3433 Web:wWw.sigov.orq/ehd UNIT IV <br /> 9�f FORS' ENVIRONMENTAL HEALTH <br /> WELL PERMIT APPLICATION PERMIT/ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t Irl <br /> COPY <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 Development Title,chapter 9-1115.3 an the Standards of San Joaquin County Environmental Health Department. <br /> ry ,� $ tCL� 1?-, Assessor's <br /> Well Location "� ^ ss Street City `= o r Zip S3 C-CParcel# <br /> Property <br /> Owner Address� 5 �— �• �j� <br /> City Seo c..k�n hZ�iip q�'�\ Phone# O <br /> C-57 ContractoraS �Q ���� dress3632 �w.�L G'�\ ity�O..�c�oW'4Lic�Phone <br /> onsul ant/Sub CntrGQ r?,5,J rAs�V ~�35\ V--\eSs V&Cit . <br /> y � Lic# Phone laO� <br /> GIS Coordinates:X Y Township 'T a Range %Z– Section <br /> WORK TO BE PERFORMED: <br /> 1g] NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑OVER-BORE DIAMETER <br /> ,9 WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER ( GROUT SPECIFICATIONS <br /> COMMENTS: X" 'ac z P'Z 5 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE\o('1 l"❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:6-112 � <br /> El EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS Sc�@ "M�FYIE OF CASING:E STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR X621 MUD ROTARY DEPTH OF GROUT SEAL ` g TREMIE TYPE TO BE USED❑AUGERS m HOSE <br /> c <br /> ❑AIR SPARGE/OZONE ,PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS e,Z. \ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH , S � .� 1-1BOLTED TRAFFIC BOX OR El STOVE PIPE O <br /> CONDUCTOR CASING PROPOSED �`� (if YES,list specifications in comment section) <br /> COMMENTS: P c h n <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 1 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> y <br /> I hereby certify that I have repared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations and all ap //a le California Laws. <br /> Signed ✓ Title/Company,:S- ` tie �rCQfr <br /> Print Name N N. \ Date <br /> ?? DEPARTME�(-Lr'/GfGf —HNT USE ONLY I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 L1 J �0 Yl -� Ce (i(j f �JOY1 l <br /> WORK PLAN DATED: J 11 V D V e /57 Vo�0 <br /> APPLICATION ACCEPTED B,Y/ lL Y 1 G InO�f JAft L, I'�7z�lif DATE, IISSUED �2-2,13 –1 j AREA I�f 'v 9 Z <br /> GROUT INSPECTION BY V I'C+o r ik !)2��� I FINAL INSPECTION BY V1[�iA JZ4-,1'Ar`6r DATE Z-z-8`// <br /> DESTRUCTION INSPECTION BY / DATE <br /> COMMENTS/CONDITIONS: S rLi��C( /�On 0 ? one– d ee D GGAy "A"I'--f2 tzek VEL f/ yt/P11 . <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 2Rb ( 111Z,00 X (,!k 488 , 00 /054 -e�' -2-3 -11 SR# 006 2003 <br /> C-57 WC7(� rt AIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 'Q(�ENCROACHMENT DOC <br /> EHD 2w,17(V )3�� V O r '` WELL PERMIT APP <br />