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rrd � "kk" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE j `,E 600 East Main Street, Stockton, CA 95202-3029 MITIGATION ox-Pj Telephone:{209)468-3449 Fax: (209)468-3433 Web:www,sjgov.org/c/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. Ave /� l� a ! Assessor's Well Location X53 .Yok�,1�e ACross Street ?Owe CS AVS. City riTLU_ Zip 7� 5� Parcel# ZZ.3"32'd IS Property'-f Owner !'1� �hcL-.//yy Address -?0 Saw :711 City_�auay�� TX Zip 15ZZI Phone# r� C-57 Contractor 1�E lyM►QnW �1$ Address 3195 L0y unQt bC* tt- I_ City q Zip�a Lic# V15ili 1 Phone6/ ConsultanVSubCntrS&00- II�1 1Address 'AO + V-ilaof. Qj. l-,WdXity , M oiM Lic# Phonegb'pb Og0b GIS Coordinates:X Y Township Range Section WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) (DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# OVER-BORE DIAMETER ❑WELL# kPRESSURE GROUT A 1.0 ❑*OTHER 1r� . C . GROUT SPECIFICATIONS COMMENTS: f �/ TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑FVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) 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 Coun Ordinances,Rules and Regulations,and all applicable Calif nia Laws. r Signed Title/Company ?7�1C� Print Name '7-;�ot ev Date p q DEPARTMENT USE ONLY J SITE MAP IN UNIT IV FILE,ADDRESS: WORK PLAN DATED: -7, ZVV d T�✓u" ' QO APPLICATION ACCEPTED BY / DATE ISSUED SIS AREA GROUT INSPECTION BY FINAL INNS ECTI N fY DATE DESTRUCTION INSPECTION BY DATE ! COMMENTSICONDITIONS: At W I P✓-� &--ec 5'i 4'1-t ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE m ze 60e; ?(/ 33p0 A44-, S la SR#DOS 152 C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT ENCROACHMENT DOC EHD 29-01 11/5/07 WELL PERMfT APP