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PqD f" SAN JOAQUIN COUNTY <br /> EVE[D)ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> '• _ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> . .• U 8 MQPhone:(209)468-3454 Fax:(209)468-3433 Web:www.s'gov.org/ehd UNIT IV <br /> IRONMENT HEALTH WELL PERMIT APPLICATION <br /> PERM TSERVICEy ,,-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 /> A,4-- CityU�+ -3( <br /> 3( � Assessor's <br /> Well Location (0 posr� Ave. Cross Street Zd - Zip <br /> Parcel# <br /> Property <br /> Owner ,N 4 L c o . o c� ` S Address FO Riox -T95 City M o c1 e 5--o Zip '15353 Phone# <br /> C-57 Contractor ✓�W Dr:ll;, � rdr-Address W06 D-d& Creek- pr. Cit SfOGj` ^ Zi qSL/S -7zo901 W69-7?v0 <br /> City Zip952-15- # Phone <br /> U-ro-. ci LarJ <br /> . ^ � _Consultant/SubCntr ,4rwI-,4v, -c Address 17 f Mu: <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 /> ❑SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS Neu{- (e <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: -d"It r-2-t' 3 F� DCShieI U-1--I�r, MwS- 1AAL-/7 <br /> Mw S'/ AA Mwl1c, Mw 17,µU141 � MwZ �. <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 CASING PROPOSED (if YES,list specifications in comment section) <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 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 ��V �/ Y Title/Company 5�a FF 1!Pd o y f S /(� �� e ip w�X k 1 <br /> Print Name J o e V A S g U e Z- Date Zz SV/v <br /> DEPARTMENT USE ONLY FILE C <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 1 0 <br /> APPLICATION ACCEPTED BY c— DATE ISSUED 2 l 1 C a AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY�I ��AAA I- DATE 2��(C) <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> z�oz <br /> 60,CO 0 2111116 SR# 513 19 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />