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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> J) <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> 8 2%aephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd MITIGATION <br /> 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. VaE II <br /> " <br /> Well Location \1Vc 14-1 fd4A (r 4"" ve"m)'� 9 Assessors f-W1 <br /> Propeo'�,,'- ruvic Cross Street lk�,/ 3 3 (150 P-0-SO A) city -Zip Parcel# R'_'k-05!X)`D 7 <br /> Owner (C� 0 Address is poet city 96CLbl-\ - zip 95-2o.V Phone# 209'-�66 <br /> C-57 Contractor �S7 Address 290 EqsiF Str&_�- City k/0�40 Lic#0 oZ3-3q Phone 3 0-6b�-2(4 <br /> Consultant]Sub Cntr Address 003 10 <br /> �Voo City 001 Lic# NX� Phone S - � L -_TLYG' <br /> GIs Coordinates:X Y Township Range Section <br /> W"K TO BE PERFORMED: <br /> M NEW V <br /> )PELL/BORING(CPT OBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> LTJ SOIL BORING# El OVER-BORE DIAMETER <br /> ❑WELL# 0 PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> C1 MONITORING C1 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS[3 MULTI-LEVEL WELL CASING CIA:Ajt� <br /> [I EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:[I STEEL [I PVC El OTHER <br /> [I VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS ff-HOSE <br /> [I AIR SPARGE/OZONE 0`PUSH POINT(GP OR CPTP—P GROUT SEAL PUMPED:0 Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (B SOIL BORING 0 HAND AUGER_GROUT SPECIFICATIONS <br /> Ly OTHER: 0 OTHER: APPROX.BORING DEPTH L6 [I BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> C?�DUCTOR CASING PROPOSED (if YES,list specifications in oprnmente t ) <br /> COMMENTS: A kd( Y ,7yn 111 <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,ar)d all ap [/C�'� <br /> cabl,9 California Laws.SignedTitle/Company PAfe-0 (_Aq, SA-7- <br /> Print Name 3con �1,\I --Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: CVLP—(4--62j­_T <br /> APPLICATION ACCEPTED QY DATE ISSUED 117� 6? AREA 5-77, <br /> GROUT INSPECTION BYt'CttA-01/-f FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: G�OfAA-(/ <br /> ACCOUNTING ONLY: AID'$ FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> dqoj ct,613 Lbz 11121 0 k S R#IQ 6-y -7s <br /> C-57 <br /> 7s- <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHO 2M1 1115107(WEB) WELL PERMIT APP <br />