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'4 y <br /> �o.Q`•'•'": a SAN JOAQUIN COUNTY FILE C <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> T leph ne:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> !fi"R Tf <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i& g4IN ith San <br /> Joaq in County DevalnnmPnt Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. PER HEALTH <br /> l N �Q���/-•�_ Asse4s gqW <br /> Well Location_4 ?6 Cross Street k}ylq yy� City Zip 37�n Parcel# <br /> Property (, / J <br /> Owner t f4 O/�+ �Y G L(t Address 325 000 C n�11�G City C Zip 9.5 � Phone# a <br /> C-57 Contractor �YQ Address q_D we- Kpo.A City jV ilna 2 Lic# MY15 Phone V5.3/,3--%OD <br /> Consultant/Sub CntrAif/CG�y(01hn{.ty Address City {C lattnc>I L i c LqPhone 510!&Z3 WQD <br /> GIS Coordinates:X 34•-W •-IZl. <br /> �'3 L J ownship _ Range _ Section <br /> T J <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# -T9->W-4, ElOVER-BOREDIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> El'OTHER ( (_ GROUT SPECIFICATIONS <br /> COMMENTS:QKA- I_F)c_r-'01n (ID3 G J n 117.E <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 /> • <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE �T <br /> ❑AIR SPARGE/OZONE `PUSH POINT(GP OR&__ GROUT SEAL PUMPED:[I Yes El No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ROIL BORING +`HAND AUGER GROUT SPECIFICATIONS�Y a � 1'VY4-6,4 Com- "t <br /> ������//////❑ ��.��OTHER: El OTHER: APPROX.BORING DEPTH q5 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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,�allca alifornia Laws-, 11 1 <br /> Signed Title/Company 14-mF_6 lLZ�W1G1rTYi k <br /> Print Name Date 3//7 Z11 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: " v 5-y • <br /> WORK PLAN DATED: Z 3 U f 1 <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3 <br /> !7,2 b13 S R#�YDZ3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT /^v ENCROACHMENT DO � <br /> FILE COPEHD 2M1 1115/07(WEB) f2"9V WELL PERMIT APP <br />