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SAN JOAQUIN COUNTY <br /> EVEDDENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> .., c1 O 8 2Whone:(209)46&3454 Fax:(209)46&3433 Web:www.sigov.org/ehd UNIT IV <br /> IRONMENTHEALTH WELL PERMIT APPLICATION <br /> PERMIT/SERtIICE�0N-REFUNDA8LE 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,chm <br /> chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location 1I tp 5 1 Ya /� <br /> l e^ /'`�e• Cross street A-%��^ R d • City N`µ^T -L'1 Zip °fr3 a cee sorl# <br /> Property <br /> Owner M'4 L c e.r..o a• `c S Address F0 11561 9 y City N`o4 e S�o Zip 'I 5353 Phone# <br /> •169-•I7J0 <br /> C-57 Contractor V 4 w D r 11 ^� , I-nCAddress �0 b D-ck Cit t it per- City t i c k-> Zip 9 S LI S Lic# 7'10101f Phone <br /> lrrD..,nd y <br /> Consultant/Sub Cntr A✓w 1 c:J,✓rJi•c-Address 17 Of M City Lic# Phone TT 3 8 -9 r C-tf <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 /> [3 SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# 7PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS Nta{ C t..tr <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: rttiS✓rC µw(- �uW7 <br /> MWyf� Mw) _ Mwlb. Al�•i'�T,/�N'141C.M�-'Z�. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASINO PROPOSED (H YES,fist specilloll"In armmont sacWn) <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,and all applicable California Laws. <br /> Signed old `�°l d y/ Y Tllle/Company 'ke i <br /> o <br /> Print Name J d e- V a f"/!j u e Z Date Z f SZi o <br /> 1/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1?5 IPAJ� MA -,tt_j <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY � dea,r+�•� DATE ISSUED Z 11 I a AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY 421A DATE_42366 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> i�oz AR 60,00 of SR# 5"73ft <br /> G57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28109 WELL PERMIT APP <br />