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p1� t,�rco WELL _ ERMIT APPLICATION FL .M SITE <br />SEC SAN JOAQUIN COUNTY MITIGATION <br />112006 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br />30- UNC 304 E. Weber, Third Floor, Stockton, CA., 95202 <br />sem' 3o R NMeN MEQ (209) 468-3449 <br />E��NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application 19 reHDby 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 />/ I I 9SZoy Assessors <br />WELL Location S�y1� ��VT��Wt LAN Cross Street City Zip G / Parcel# db <br />PROPE Y _/I 1 r Zi Phone# C <br />Owner 4 ," Address // 441 r''� mi"Al City p� <br />I Q � f�✓'1 <br />C-57 Contractor Q Address 3b )� 0wtcL (irLk City l`a1,1v Zipq57qL Lic# 7175k7 Phone# 910 f03}? -4 9 <br />c . 3 J Ca �3 Z <br />Consultant /Sub CntrT _k dress 33 �� `""` M' Cit_SU �Gy Lic v"''` t/T /'Phone# S3�%-67b- 706 Z <br />GIS Coordinates: <br />Y <br />Townshi <br />Ra <br />Section <br />WORK TO BE PERFORMED: <br />VNEW WELL / BORING (CPT, GEOPROBE, <br />HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />0 OVER -BORE. <br />DIAMETER <br />[] WELL # 7MW% 0 <br />0 PRESSURE GROUT <br />*Other <br />GROUT <br />SPECIFICATIONS <br />COMMENTS: <br />^� <br />l� <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS / <br />! <br />MONITORING -RHOLLOW STEM <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br />' <br />[] EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL k_PVC 0 OTHER: <br />[] VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL �i� TREMIE TYPE TO BE USED: 0 AUGERS X--KOSE <br />[] AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: roles [] No (NOTE: MAXI)AU FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS ;�K_.^l o C0 <br />[] OTHER:OTHER <br />APPROX. BORING DEPTH U 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />_0 <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: SSSS Sd 1t/ ^ SZ <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />11-J <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 in accordance with San Joaquin <br />County Ordinances, Rules and gulations, and all applicable California State Laws. <br />C+ asG�1_2 <br />Signed x i JV �/ Ind Title/Company Yl I ( I i� <br />Print Name �me�i- V - 1 ( e t' e Date — <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: z? 5-a we,+ fja m rn er LQ rL <_ <br />WORK PLAN DATED: SeI2+e>,11916_r le 2_06'' <br />Application Accepted B V j G+D r ` L . Date Issued (� 1 3 -� �e Area 14 5 q <br />Grout Inspection By f l ejbP' L' ill �dY]'Y1 Ls, Date Final Inspection By <br />Date 7/ 21 b G <br />Destruction Inspection By Date _ <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: I AID# <br />FAC# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK # I REC'D BY I DATE <br />3581 a'9Y.00 fr34,S.00 <br />3503 f.274.00 <br />s'K -0; 6 6 4'7 3 8 <br />INVOICE <br />