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FILE COPY <br /> 211 NEpLTH SAN JOAQUIN COUNTY <br /> EN � CES _ <br /> 'ER ENVIRONMENTAL HEALTH DEPARTMENT --- <br /> N i SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> \04 / , 7 I Telephone:( ) - ax: ( 09)468-3433 Web:www.sgov.org/ehd <br /> lh2094683449 F2www.sw-qov.org/ehd IV <br /> WELL PERMIT APPLICATION <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"' Standards of San Joaquin County Environmental Health Department. <br /> /'`}'w 1 ' /,1��/� Assessor's <br /> Well Location_�-� ai� f0 ,Cross Street Mdc bV [l�t�— City '1Y6.11t Zip �`J�'�In Parcel# 25o CM0 13 <br /> Property <br /> Owner Address (11G1, 0'). <br /> � I�, <br /> Ut�12(Z (.;1ti�1 OIC N S I r111Cii�a rl S�,S ;;I"i,��UCity !��S f Vt C Zip Phone#r11�.� � ) L- 0 a , <br /> C-57Contractor {0t,j�--Q C003.J i (v% Address «1��j �, "I�;�C(1C )'V"- City Sa,112\(t.Vil zip '1061 U Lic# 9Or( 9 Phone pOSS <br /> Consultant/Sub Cntr AKMNS Address City (1:� Lic# Phone `.a 10'2B-32r ) <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> .NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> EjSOIL BORING# G P` ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: C',PT (xXiV��r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF p CASING:El STEEL ❑PVC ❑ OTHER <br /> El VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL ld OV(�V'R-IRkM)EETYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE IBJ PUSH POINT(GP OR CPT)-'� GROUT SEAL PUMPED:I4 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [&SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS CCI(YU-AI r1�I`hr i �r�Iy/G�12 r <br /> ❑OTHER: ❑OTHER: APPROX BORING DEPTH 7t7 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (it YES•list specifications in comment section) <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 1 (iF l 64 Title/Company (r <br /> i,Y { ' <br /> Print Name Pb <br /> -cc L-lo f,� Date cot I3/Ug <br /> /i <br /> DEPARTMENT USE ONLY l <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7 v' 41 sy, <br /> � , /. Gs-/ / <br /> �� rpO �/ <br /> WORK PLAN DATED: f L'' L/ oaCif�� // <br /> APPLICATION ACCEPTED BY Av,- DATE ISSUED AREA D� <br /> GROUT INSPECTION BY FINAL INSPECTION BY 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 PERMIT/SERVICE# INVOICE <br /> R# L� tW3 <br /> C.57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 7 ENCROACHMENT DOC <br /> EHO 29.01 1115107 <br /> WELL PERMIT APP <br />