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. ` SAN JOAQUIN COUNTY - <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 AU6 ' L0411ITIGATION <br /> ��.,. Telephone:(209)468-3449 Fax:(209)468-3433 Web:www. eh UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES t 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 J aquin County Environmental Health Department. <br /> 5'1 � � Assessor's <br /> Well LOcatIOn14W LJ"4 Sctiol4c RA. Cross Sires (,fa City Tr'a'-I Zip J-2317 Parcel# Zo92HOt2 <br /> Property <br /> Owner -rkcr,rnl n.cr Address 11YRODIy0- Zip 'IC 377 Phone# 2 - SXS'-6 111 <br /> A6I +II UciPAj Ob IC•57 Contractor Cl le Dw <br /> hon <br /> Consultant/Sub Cntr klciwfddc/ Address tool Rrd.-R:rF..rl 2�1. City SFPCL Ho.. Lic# Phone (Zw) 1169-43eo <br /> 5u,rc >d I--O <br /> GIS Coordinates:X GZT S i S`Y ,Y 1-056616 ,Township 1f2 5 Range 4E section 36 U W y <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL O99 G(CPT, E75'fi�iR HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> 1-1 WELL* ❑PRESSUREGROUT Frc� 41�11 <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: TfY, 1/n Storry <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Y . ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING:0 STEEL ❑PVC 0 OTHER •� <br /> 0 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL ZS 1-0' TREMIE TYPE TO BE USED❑AUGERS❑HOSE, u(A, <br /> 0 AIR SPARGE1020NE 19 PUSH POINT(®OR CPT)_ GROUT SEAL PUMPED:0 Yes [9 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30')/ V- <br /> 13 SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Y <br /> 0 OTHER: ❑OTHER: APPROX.BORING DEPTH 7-C 1 ❑BOLTED TRAFFIC BOX OR ❑STOVE PI <br /> CgNDUCTO <br /> COMMENTS: ING Epc�. If YES,list speal'utions In comment section) <br /> �IL �lutcl��lp YF�t�Sal ✓Y ! SL)l-tA7�. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS bG 1/ <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS �� C <br /> I hereby certify I hav repare his application and that the work will be done I accordance with Ban Joaquin Cou ty Ordinances, ules a d <br /> Regulations, I ,/able C fornia Laws. <br /> Signed C Title/Company (�� ) / �1 ✓' ��f <br /> Print Name M12Q to C6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1�4 9oo _C(_A f r LP I <br /> WORK PLAN DATED: a! -j-at 1 071r <br /> _r <br /> APPLICATION ACCEPTED BY _�{lrwv�Mi 6•, DATE ISSUED 0 $ AREA <br /> GROUT INSPECTION BY AI l f eK FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> zC'i l $S°I 13286 p l `1/ f/o7l SR# SS; l6 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 29,01 11/5107(WEB) WELL PERMIr APP <br />