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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> i a ;�; SITE <br /> : 3 , 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> \, <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/end <br /> a�.,..._ <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 /> Well Location <br /> _ �_....-_.._ Cross SVeet4/ t Li Sr!/ <br /> � Assessor <br /> Property city Parcel <br /> owner C4 1, Address- / . <br /> v � <br /> City 14r 1 r �L— <br /> / _/ ..__.__ Zip 3.36' Phone#2l -9f 257/ <br /> C-57 Contractor $oaR+ �r, <br /> Address �� 5�� rST City�J ZIP 9Sldz Lic# (Igq(186 Phone 9l3/ld <br /> Consultant/SubCntr Address ,Yj-e,VirY�� Ciry �1 Lfc#_7OIE-�,hone�� &�4tS(_ <br /> GIS Coordinates:X.- ;Q J Y -SI77 9"6 _,Township %/$ _ Range_yA�5_ Section <br /> WQRK TO BE PERFORMED: <br /> NEW WELU13ORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> [3-SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# ELI-!8A ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑//MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _1�G ❑MULTIPLE CASINGS�MULTI-LEVEL WELL CASING DIA: h <br /> Id <br /> EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS�(n, __TYPE OF CASING: STEELj PVC [I OTHER <br /> /❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL_QJ TREMIE TYPE TO BE USEDXAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:,P(Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING El HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: OTHER: �n��— APPROX.BORING DEPTH 1,35 of lO ❑BOLTED TRAFFIC BOX OR STOVE PIPE <br /> CONDUCTOR CAST G PROP SED _,-______ (if YES.list spedfiratlons In wrm�ent Iec on) <br /> COMMENTSR C LIED - IIS � la6 - ;C �[h�fd : goo=�)0 Srlee <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 preare s application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d all a C Ifo is Laws. � � / <br /> Signed Title/Company /dY' C D /s <br /> Print Name a u/vrR t•,rt Date / !I <br /> I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT 1V FILE,ADDRESS: <br /> WORK PLAN DATED: C Ul2w O-c <br /> APPLICATION ACCEPTED BY DATE ISSUED 2191bf AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: Z 3-�b <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC -WAIVER C57 LE ER OF AUTHORI TION TO SIGN ERMIT _ENCROACHMENT DOC <br /> EHD 23.01 11/W7 <br /> 3,3-S �O y I +0 0-5 Z WELL PERMIT APP <br /> 7. 3�3 - <br />