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,o of �o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> P Telephone:(209)468-3449 Fax.(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> GrCOR� <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 t e Standards of San Joaquin County Environmental Health Department. <br /> /N tleRQ 9j� w I,?Y ROAD Assessor's <br /> Well Location 5`S M f644WAk 33 Cross StreetCity\16RN ALIS Zip %355 Parcel# 26S- 1160 19- <br /> Property Qn <br /> Owner_ UPR 12 Address1400VO!!WS ST,STOP Ib90 City OMAO ZiAt��Ib Phone#x}42-,�• y <br /> -OG&3 <br /> C-57 Contractor K I WILU1J61 Address 220 N. EA5T 5r city W00VL 1Jp ZipIS17PO Lic#&23"b4 Phone 2-.q2-,q <br /> bb$- <br /> 2n� c� <br /> Consultant/Sub Cntr SA I G Addres938CDWATTP - _SU ffE-z City ATAMENZ Lic# Phonell b'q-1,1 31`15 <br /> GIS Coordinates:X Y ,Township Range b AS"l- Section 2#-I q <br /> W K TO BE PERFORMED: <br /> EW VIjELUBORING(CPT,' GEKROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW)(`SOIL BORING#_ I� S , F g& IJ OVER-BORE DIAMETER <br /> WELL# ',PRESSURE GROUT <br /> ❑ <br /> *OTHER GROUT SPECIFICATIONS T_ 6;tE <br /> COMMENTS: �- ( E0PQ()5F 60IZItJC15 TO ^ _3Sf <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3.25" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:0, <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS N A TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER N A <br /> ❑VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TD=35TREMIE TYPE TO BE USED❑AUGERS)(HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yets�KNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS EAT- CV-M ENT <br /> KOTHER: W I TEAW. ❑OTHER: APPROX.BORING DEPTH 3 6, ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: C7Ed PR( 80121Nf�F_ WI LL HAT iEM�0eA�2y' El.li H 1S toNST00cr✓P � A pi2E?ACIGEp <br /> F I L��G EN�p 1--4 C- CAS-1 4 6 . <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 th application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,an all applicable Califo is aws. <br /> Signed Title/Company fftzecT ENV( N M >�SGI n1TtS� I SAl L <br /> Print Name L A PRY I L V A Date <br /> DEPARTMENT USE ONLY Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: StI .2,00� <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA f <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE �) <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 4-117 Z'Y SR#4 <br /> C-57 WC -WAIVER C57-LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />