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SAN JOAQUIN COUNTY <br /> Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:vwvw.sjgov.orq/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location 35 Z. S Wel�y ross Street 9 1;41 W Q 33 city Y Vlo( I Zi C Assessors <br /> Property I l �/ (��Q zip25335 Parcel# 25s'0li-Q7/ <br /> Owner N O r M a K) W U 17 1 e-&r ,,Ar1dress a VI 1 V e City \e I 1 �C/� Zip 0�Phone# 15 �o' �1 5 <br /> C-67 Contractor ` Cry t`i�ddress / iC <br /> ��19 �� �1�Q City 1 l Zip��gLic# 2����-ls Phone j L <br /> ConsuManUSub Cntr �e"In�(UM'S�KAddress�O� 1Jfo�((JGt y,Ste�7-pity Oa k lah uo# Phone 559 38�7��' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER') &DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER Z. 'j,/ <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ^^I/W <br /> [I EXPLOSIVES DETONATING CARD <br /> COMMENTS: 1'I I <br /> St iO✓i !uC Ori <br /> TYPE OF 1 S TYPE GAN&FRUCiiGN SPECIFICATIONS <br /> MONITORING 'Oli0LLOW STEM DIA.OF BOREHOLE 3,7- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2-11 <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL WVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL�_TREMIE TYPE TO BE USEDNAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS u/Q CI fA&I d CP A 1 e►) <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH -I D'7 5/ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED rir YES,list speditaeona in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify I ve preps a n and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations{ plicable ) b <br /> Signed �� ° Title/Company MA P1 a. eVAif - SAI C <br /> Print Name W I ll i awl (OW I l& Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED U AREA <br /> GROUT INSPECTION BY p FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BYDATE 7 S 1 n <br /> COMMENTS/CONDITIONS: 11 ,p S C 1' M <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# e RECV'D BY DATE PERMITISERVICE# INVOICE <br /> a bZ � O MoD" �� !o (� �� SR# V"�3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SI GNPERMIT ENCROACHMENT DOC <br /> EHD 29-01 10128109 WELL PERMIT APP <br />