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SAN JOAQUIN COUNTY soCC��� � ropy a <br /> 2 a EN ONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-302 `1�a <br /> �... _ .. `� R 0 �cyy Z009 MITIGATION <br /> P i Telephone: (209) 468-3449 Fax: (209)468-3433 Web:www.slgov.org/end UNIT IV <br /> ENJIRON1r1�IdT HEAL,,WELL PERMIT APPLICATION PERMIT/SERVICES 0#04"&& <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. <br /> �ti U E, - �r� S�ocl(1.4 �SZ DS Pacel#rs ILI3410411 <br /> Well Location � 4 �W.IM�M( �� Cross Street F•( City II II Zip G <br /> Property f V n /I �.�, S7vc((fv I�-Ip Phone# <br /> Owner �`4 P%4S 7L) ccl*GkAX Address 0�-3 sg. f-/2�rhAh NO City , Zip <br /> C-57 Contractor 4lUv�yiry� ©r.,`�v� Address SSU vita 2.r,� City Lic# 71u a7H Phone "107-3'74- k.3 oc <br /> Consultant/Sub Cntrs �(/'^5 L4."-d-tw«t�ddress 310 Cr+w„(Cyy, (k�l( fir,1# City CS i+.t.^oy p�I( Lic# Phone 536-67G-'�G4 <br /> GIS Coordinates:X 3T. L95 Y �I�I.��J'/ ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# [:] OVER-BORE DIAMETER <br /> m WELL# M I✓' ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,MONITORING IIq HOLLOW STEM DIA.OF BOREHOLE S p ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 5Lk 40 TYPE OF CASING:❑STEEL Pip PVC ❑ OTHER <br /> L <br /> ❑VAPOR [IMUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO BE USED 90 AUGERS❑HOSE <br /> ❑AIR SPARGE1020NE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:6(1 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS t1.CA� C.Ioyf,^I <br /> f <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S C9 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (RYES,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 /> Regulatto an all applicable California Laws. I <br /> Signed Title/Company P,01fl G-Polu�+rS� S"4-1 �h Ui1^utrt wt,cHl'�I?^( . <br /> Print Name All" bLy Date 3/27/x9 <br /> I <br /> 'y/2Q DEPARTMENT USE ONLY ' ,//'�// <br /> SITE MAP IN UNIT IV FILE,ADDRESS: [ J//�V 7 �c D � 9 , " " <br /> WORK PLAN DATED: "' -// D6 <br /> APPLICATION ACCEPTED BY D $�� AREA 0 <br /> GROUT INSPECTION BY FINAL INSPECTION BYE' j� 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 PERMITISERVICE# INVOICE <br /> 3501 /Z !-0 SR#Q a <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT E�49�RpGA�6�N�ME#T-DOC �/ <br /> EHD 2MI 1115107(WEB) l.wl/�J VVELL PER45� <br />