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' SAN JOAQUIN COUNTY <br /> f'` ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;� SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:vwvw.sjgov.org/ehd <br /> UNIT IV <br /> WELL PERMIT APPLICATION <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 /> / / Assessor's <br /> Well Location .4A/6 Si4e4A �d St Cross Street ,S�`ne{Tr Ln City sh>-_kAin Zip 2S7-0 Parcel# i/9-080 -1y <br /> Property <br /> Owner Tho.»nS S"ow-go/7 Address J q,20 City Zip f-r.2o7Phone# 204 VRL-/oaf <br /> 73090'/ <br /> C-57Contractor Lc.) n Address 00 QbY 57n City .4o4(; Lic# Phone 299 362- 4(000 <br /> alaslace-mak'- l 41dtz) 4.e-s1 / <br /> ConsultanUSub Cntrt q•faC,rt r, Address JAS7 .,SeQ['cm i4&- City S.ccr�..x�lt Lic# Phone 9/6 371 <br /> GIS Coordinates:X-J-+Sg 3 <br /> -IS,j /r ,Y-/.L/ 7,341i ,Township Range /2 (a G Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROB€,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®SOIL BORING# 6 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> r_1*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING -0 HOLLOW STEM DIA.OF BOREHOLE A ❑MULTIPLE CASINGS❑MULT!-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 I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations7�p <br /> plicab e C ifor <br /> / <br /> Signed ' / - Title/Company 56 . �Q t ��o loy t� �a��ace- ICwk�fi�5icc. <br /> Print Name v r c Velvlli 6�- IIA-KA, Date z <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 L/ <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTaEY 'n✓�`�� DATE ISSUED 7 'O AREA <br /> GROUT INSPECTION BY ✓v`t7t-� FINAL INSPECTION BY DATE g <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 /> 9-2 <br /> �e G ' SR#/�(�� <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />