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I" 1 ' 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> h,. a;�' Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.sigov.ora/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - p <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. �S/�4/ <br /> 1 [c • Assessors <br /> Well Location 13YAO ly.lkov Y,ton cross street W. r;nava,. eA. <br /> _ Ci ty �� zip 95loZ Parcel#n551�91 <br /> O <br /> Property <br /> Owner' Address I W,3(n . �o✓M for <br /> city Loci; Zip el6oAAZ Phone# <br /> f Te51t^�-- q rr <br /> C-57 Contractor ���r D.rll_(,n� ABdress n L6,29- Fd City Ha,'bm? Lic#%S/(,ii- PhoneLlkr)313-S800 <br /> 2„.. <br /> ConsultanUSub Cntr'B,n So.,...(ira.,e_ Address3'IS1 L City <br /> ,. I/lyosa..d A'(1 Lic# �Phhone Ozo ??Vgr-.2 } <br /> GIS Coordinates:X ��•. -- ,Y IZ-t.39&, Township .�wJ Range_ES c. Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAN UGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ,9 WELL# ❑PRESSURE GROUT <br /> El'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> it <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS4 Yy�� TYPE OF CASING:0 STEEL I)r PVC 0 OTHER <br /> '''' <br /> 0 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL &TREMIE TYPE TO BE USED QJ AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:ffYes 0J No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS POrlru '4 ��I f2Ntr <br /> [� r p, <br /> ❑OTHER: 0 OTHER: APPROX.BORING DEPTH YO CI ❑BOLTED TRAFFIC BOX OR IYl STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in mmmenl ion) <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,a d all appliGa�Ij���alliffornia Laws. 'o <br /> Signed �B 'o rel \W1Ja P. Title/Company 06�/if ,S bxI i )Li <br /> PrintNamemag& S Date 8�Tly <br /> ' <br /> > / DEPARTMENT USE ONLY _ �� Sb <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /V- <br /> WORK PLAN DATED: O <br /> APPLICATION ACCEPTED BY DAT&! `&Z—iiAREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY_ V DATE; Q <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 7ylD 3 <br /> 17-13-OZ JAR#0 515 <br /> C-57 V WC V, -WAIVER C51 LE E F AUTHORIZATION TO SIGN PERMIT E ROACHMENT DOC <br /> O <br /> EHD 28-01 71I5/07nvEe) Z' WEU�PE M�A <br />