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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 1677 11.wle"4 ffd .pct/LL �4U<- Cit �o—Zi 171-?349 Assessor's If— Well Location � — Cross Street y p __ Parcel# � _ _-- Property1104.410 104 /p L Owner_ Ce —---------- Address -!6L72—AWq /�J�,,, City L �__ Zip—p_ _Phone#—q—_—_--_ C-57 Contractor E� Address301 of h L^'0i N!tV C City�Iy S __-_ Zip /S,0n3 Lic# 05170_Phone Consultant/Sub Cntr Address_ — City -- Lic#— _Phone GIS Coordinates:X ----------- ,Y _ —____ _,Township _---_------------ Range—_—_— Section WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROB`E,HYDROPUNCH,HAND-AUGER,OTHER*) C] DESTRUCTION(CHOOSE TYPE BELOW) ;NSOIL BORING#_ 57113-1 _ ►.fsh SB_tS-- _ ❑OVER-BORE DIAMETER__ ❑WELL# __------------- _—_—_--__ ❑PRESSURE GROUT _ ❑*OTHER ------ __-- GROUT SPECIFICATIONS ------------------ -- COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _Z!i_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY __ DEPTH OF GROUT SEAL _ - __-TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE PUSH POINT(GP CP ) GROUT SEAL PUMPED:❑Yves [I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') SOIL BORING ❑HAND AUGER____---- GROUT SPECIFICATIONS "- `' ❑OTHER: OTHER: ________ _ APPROX.BORING DEPTH 2 ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE /! CONDUCTOR CASING PROPOSED (ifYES,list specifications in comment section) COMMENTS: (�.�e-o NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,,sVd all applicable California Laws. Signed —-------------------------- Title/Company - �----�!' Print Name _90"0 n,-- R/ --------------------------------------------------—DateJ 1' / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: &R WORK PLAN DATED: C -2.0 —---—-------- — APPLICATION ACCEPTED BY _ DATE I SUED —_AREA '197 GROUT INSPECTION BY FINAL INSPECTION BY 1 0 _ DATE DESTRUCTION INSPECTION Y-- DATE_-- COMMENT / ONDITIONS:�b 9C R/.l)jj_— �L0 / �V1 +��1 V --- _ t -- - - ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE b/' 7 �0,7 tSR#045((27 C-57 WC WAIVER _C57 LETTER OF AUTHORIZATION TO SIG PE MIT --------ENCROACHMENT DOC EHD 29-01 11/5/07 WELL PERMIT APP