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SAN JOAQUIN-COUNTY 2' ? ENVIKONMENTAL HEALTH DEPARTMEiJT SITE Stockton, CA 95202-3029 • , 600 East Main Street, S MITIGATION Telephone: (209)468-3449 Fax: (209)468-3433 Web: www.s'gov.org/ehd UNIT IV 71 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 Envir nmental Health Department. 3 _3f Assessor's Well Location 353 WeltY�d U�1�s Street �✓ City Zip % Parcel# Property tt!� / 0D&o �''? Cit Zip r ! " Owner r Address / y / /Phone#r �'n u.^�u C-57 Contractor Address /V. Ca[S�'�� City /d Lic# Phone 7 6ha� P 1 Consultant/Sub Cntr 5A-Z6- Address �r(rYJ//�d�,_�w�t ��ty 1d Lic# �Phone rj' I0-V� GIS Coordinates:X ��K Y.r�)]I �g�)t_ 77�b_�,Township vC� Range _ Section - WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') (CHOOSE TYPE BPLOW� ❑SOIL BORING# OVER-BORE DIAMETER El WELL# 4DESTRUCTION PRESSURE GROUT ❑'OTHER GROUT SPECIFICATIONS COMMENTS: - TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE __ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE V1 ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') li ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER. APPROX.BORING DEPTH ❑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, an all applicable C.Qlifornia Laws. Signed �/�Jam_ Title/Company Print Namey 'l/!'!' _Date 10Q DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,AD ESS: �� P,��p"�) D�--� P2 5�8b�3 WORK PLAN DATED: �_D/�' / ,Q — �J h APPLICATION ACCEPTED BY �d� [`^'b `�L _ DATE .- AREA GROUT INSPECTION BY 7� _ FINAL INNSPECTIOk4 BY DATE DESTRUCTION INSPECTION BY COMMENTS/CONDITIONS: CUIeW I LU•r SOU ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DA E PERMIT/SERVICE# INVOICE 0 S R# /) ;-l� I C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIG P MIT ----ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 11/5107(WEB)