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x'-0' i,"`� `✓ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT t. SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> O Telephone:(209)468-3449 Fax.(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �Q$ <br /> SEP N�P`�N WELL PERMIT APPLICATION <br /> �`Rpq�MEN Rv�SES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '"'' <br /> Ai ��ts,RetebEy made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance win <br /> Joaqutn County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location 1U 101- A,. W,ASov� WN ross Street Soiv%v*,AP++; Lcke c Cit S>Loa Assessor's <br /> Property d Y k+0 ti Zip 9 S20 5 Parcel# 11-1-0100- 3 j <br /> Owner_JoIA� 4� /utixine Fe 1r✓q i oto Address T-0. Box 751 City Lo 8 i Zip 79241 Phone# 431-2 7o v <br /> C-57 Contractor \J411d W-X-!:05,S.nc. Address PD 6071, 9-10 City Lo d Lic#Z2D90yPhone 309 - 'f to v o <br /> Consultant/SubCntr Ird'ov*%A 'ZC�'o Address <br /> 71II I''1 Mu:r i��Qe 7F City £S cot IL—. _ Lic# Phone - -$ars! - q�is'i� <br /> GIS Coordinates:X 3�- (�3 Y _��ti1 2'f I Township Range Section <br /> WORK TO BE PERFORMED: <br /> i59)NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> ElSOIL BORING# [I OVER-BORE DIAMETER <br /> `OTHER VIEW • W ��• /OW'ZI 0L0.5 ❑ PRESSURE,GROUT <br /> Ll GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING IPHOLLOW STEM DIA.OF BOREHOLE 1 N ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS K U TYPE OF CASING:❑STEEL 15 PVC ❑ OTHER (� <br /> Y,VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Zq F+ TREMIE TYPE TO BE USED P§AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:52 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS N tKi n eo j} <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S 5 F}. Ij}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,and all applicable California Laws. <br /> Signed Title/Company 5�u!'� iJeo�vyl S'� /fj-rov••c� ZE✓o 'q""'�7SIS <br /> Print Name _ Joe. "q Date <br /> I <br /> DEPARTMENT USE ONLY �(lQyt 03 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DfiTE -O ' AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE`V <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT R MITTED CHECK# RECV D BY DATE PERMIT/SERVICE# INVOICE <br /> 3501 �� Zo ,ZL-o # <br /> C-57 WC -W ER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) <br /> WELL PERMIT APP <br />