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'-" SAN JOAQUIN COUNTY i <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 3 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> a <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sicov.ora/ehd UNIT IV <br /> �c <br /> WELL PERMIT APPLICATION <br /> f <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 /> nq <br /> /)) Assessors <br /> Well Location l f-63T5ielx ,/V rocs Street✓`CAQ 1 me- city ,s/OY•. Zip Parcel <br /> Property ' I 'II <br /> Owner C kc v las (3 e.&R Address b�/J'YA��pPn City:VNf0 ZIP 125-357,Phone#; _ <br /> ``'' /n� <br /> C57 Contractor rt Address 950 l7/I L..L IK�,� City n,, n2�ZipSyy�s�Lic#(01-6"(0 �Phone5'25313 <br /> S� <br /> Consultant/Sub Cntr�TL AS SOC/a Address—I)l2) -aae, i&-/ n Q�-City /j0 �O Lie# Phone2lJ9�S79�-7iZ2-/ <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORME <br /> NEW WELLIBORING((Fjr GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# I C- pr ❑OVER-BORE DIAMETER <br /> ❑WELL* ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS j <br /> ❑MONITORING ORING ❑HOLLOW STEM DIA.OF BOREHOLE 2. ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> i <br /> ❑EXTRACTION ❑AIR HAMMER)DRIVEN CASING THICKNESS—TYPE OF CASING:O STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL 13 o TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE bg PUSH POINT(GP OR CFr)e)P1_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOILBORING [3 HAND AUGER GROUT SPECIFICATIONS 11/en+ CeAAeK+C?r0"f- <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH /3 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR SING PROPOSED lit YES,ilstspednra m In cammenl ssaian) <br /> COMMENTS: CA <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 d. appllcabl Callfornia Laws. /1 - <br /> Signed O Title/Company �G• e.-O <br /> Print Na 1n�`+ S -1" Q(1 Date !41yeAe'l <br /> I <br /> DEPARTMENT USE ONLY I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 113I0T- C� <br /> APPLICATION ACCEPTED BY IA\-.-- rrkin <br /> DATEISSUED 2 O AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE I <br /> DESTRUCTION INSPECTION BY DATE , <br /> G <br /> COMMENTSICONDRIONS: f! <br /> i <br /> ACCOUNTING ONLY: AID# FAC#. ' <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> ai 411. 0C),+1 oo��;I (r ( .t zl 08 SR# ,04-44 <br /> C-57 WC -WAIVER -_„�_C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 2"1 11M7 3 WELL PERMD APP <br />