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SAP! JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 1 600 East Main Street Stockton CA 95202-3029 <br /> ' r Telephone:{209)468-3449 Fax:(209)468-3 33 Web:wmrw.sigo�.or Ica ehd MITIGATION <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YE-AR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install t Ila 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 C unty Environmental Health Department. <br /> Locationrrt e Assessor'` €Well Cross Street itytParcel#L c1 <br /> Property, <br /> 1 <br /> h rE , ) <br /> Owner i Zt!✓ FSA il0r?4 e(,CA Address ����- �� <br /> zip"' t Phone# P-7 o_f <br /> C-57 Contractor �t�, :`' 1 E}ry5 Address t }A& ' y �} ti` e's Zi G� —�,r��r� �' <br /> r i'[f�'r- Cit :1 7 !� r p r 5� 1•?� t P-'h 4 <br /> t _ t !LIC l. ) ` } y <br /> ConsultanElSubCntr,r �_ Address 3�5 'u1�u,f r € ity4}X'i`-iZ'I`i Lic; J��' z�•-rPhoneJ� �L (.y' '�; �F <br /> GtS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: ,�,� <br /> E]NEW WELUBORING(CPT,GEOPROBE,HYDP.OPUNCFI,HANG-AUGER,OnHER*) h DESTRUCTION(CHOOSE TYPE BELCV%) <br /> ❑SOIL BORING# ❑-AVER-BORE DIAMETER <br /> ❑WELL# fR�PRESSURE `zaj rn�y- <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: v C ` <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 19 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ©MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING IDIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREM€E TYPE TO BE USED❑AUGERS©HC-SF <br /> AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)—GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 34) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ©OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPO ED {if YES,list sp=cifications in comment section} <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGRE MENT OR ENCROACHMENT PERMITS <br /> 46 WORKING HOURS NOTICE REQUIRE D FOR INSPECTIONS <br /> I hereby certify that l have prepared this application and that the work will be done I ccordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and aU applicable Ca"fornia Laws. f <br /> Signed __ T` � Title/CompanyI "?U <br /> Print Nameti c€ t�c� mak, J DateL-31 IF <br /> DEPARTMEN BE NL 7 `'y��� •-i; <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z-I V I c r,!_ 191 <br /> WORK PLAN DATED: ey A - <br /> APPLICATION ACCEPTED BY r l`j I .�.i. `-,t-s{ <br /> DATE SSUED y7-- <br /> GROUT INSPECTION BY FINAL INSPECTION BY "4 <br /> DATE <br /> DESTRUCTION INSPECTION BY—� 0"-' DAT! 5� � <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# fFACPE CODES FEE INFO AMT REMITTED jCHECK# BY DATE PERMITISERVICE# INVOICE <br /> � � g• o_o 0 <br /> z t JZ)Ia/6-6- SR# 56135-- <br /> C-57_WC WAIVER C57 LETTER OF AUTHORIZA IONTO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107 <br /> WELL PERMIT APP <br />