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r' 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.sjgov.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 Joa uin County Develo ment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. / Mr,A1 S//DE �7= eleloA -C�Y oAc / _s�o / e� Assessor's 3a"'/o Well Location «�Di/GG Cross Street City �� y Zip/5377 Parcel# �r3— Property ,h Owner:r,)C PhWA r.CM14 A05 ress IS/O f/iii 2t L%11��Ci ,t/'C.2�C/GD✓Zip 9�1 W phone#C.20� O�r3 69 6 C-57 Contractor L`y ��/�� ress ��d SP�4 0��pity ~//�� Lic#71 yP 1.S' 70 ConsultantlSub Cntr Address City rr Lic# Phone GIS Coordinates:X Y Township J Range Section Ao WORK TO BE PERFORMED: � IJEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) [j DESTRUCTION(CHOOSE TYPE BELOW) /\ El SOIL BORING ❑OVER-BORE DIAMETER ❑WELL# �_ — ❑PRESSURE GROUT ❑*OTHER GROUT SPECIFICATIONS COMMENTS: //✓ST/PLG 100 -oee'RV lF/YI!G•/ e/�,00 Q*,x!/L L c /l_r /I/E/A.-.Ae TYPE OF WELL I ```,N555STALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING y�l HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ALJ EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESSQ-f-I ^^ TYPE OF CASING:❑STEEL ❑PVCMOTHER (❑_VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL K`� TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FA L DEPTH IS 30) _ ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S' i T ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) COMMENTS: 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,and all app Ica a California Laws. /� Signed ��a Title/Company /!/ Alas x Print Name _�/llllit.lt 4Z Z r.44 4 Date ��S e ,01 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: WORK PLAN DATED: APPLICATION ACCEPTED BY ,r � Q �/* DATE ISSUED /� IFA GROUT INSPECTION BY /l��I1 f ��l `�-! p FINAL INSPECTION BY �ilr I E DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: �lu u'1'I AN JOA OUIN COUN JY ACCOUNTING ONLY: AID# FAC# EALTH DEPARTMENT PE CODES FEE INFO All REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE 4471 W py,wS S, SR#405-5 . C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 11/5/07(WEB) WELL PERMIT APP I