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SAN JOAQUIN COUNTY <br /> C i <br /> ENVIRONMENTAL HEALTH DEPARTMEN f SITE <br /> f. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web:www.s*gov.org/eh UNIT IV <br /> ,.g.0 i F o Ra... <br /> WELL PERMIT APPLICATION FILE COPY <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 Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. '7g <br /> 3033 3. S i R�v`� W, SEM- �R�NTA f'X W-X> Assessor's <br /> Well Location Cross Street NutJf o Ro RD. City 3TO42ICTaT4 Zip SParcel# /06 <br /> Property 4*04LHbr'1 3t}oo wA6NER II�kSHTS <br /> Owner Fd1L.M ems' � Tb <br /> Address RLQ. t ZCo3 City Zc-y-- -twazip_sC39PPhone# 4&&' 0g�8 <br /> l-1 <br /> e� G <br /> C-57Contractor 5 � Address !01071 $E'�SA S"� City L1t3SAMCemp-Lic#1�Phone (2S"37~G7,5m <br /> Consultant/Sub Cntr -b C►V1E Address City Lic# Phone <br /> GIS Coordinates:X Cos 57Z, Y 4 19 94 67 ,Township I N Range '7E Section 1-7 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, PR HYDROPUNCH,HAND-AUGER,OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> 'SOIL BORING# O ❑ OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS. <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 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 SPARGE/OZONE PUSH POINT(2)OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS N%_=✓kT eEl-'tE 1JT <br /> ❑OTHER: ElOTHER: APPROX.BORING DEPTH 4 FT ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES.list specifications in comment section) <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 all applicable California Laws. G c�coN <br /> Signed Title/Company Q . SC/L-►JI1,TW— Chi—�S��tT1��T5 <br /> Print Name G�10V-S_TZ_-710VDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 36 33 S. S±Q f& `R o Lj+e_GI g W. Fro of-a-a e- Rd . <br /> WORK PLAN DATED: \ D e e—te kw ey- 3020 41 <br /> / <br /> APPLICATION ACCEPTED BY Y l C j4f;a M, art n" DATE ISSUED l- l(-/Q AREA .S <br /> GROUT INSPECTION BY YIZ FINAL INSPECTION BY fln <br /> DATE <br /> DESTRUCTION INSPECTION BYf DATE <br /> COMMENTS/CONDITIONS: Ad%la Yi C erne� Of D r i rtA s + 4e U r �ee f 6 s a <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 2905- 89.00 89. 06 OG 70 '18 LZ � /-//-i0 SR# 605-9i2 -70 2 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />