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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www sjov orq/Nhd 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 1115.3 and the Standards of S n Joaquin County Environmental Health Department. <br />fu/��1nohor <br />(IL�. A'Or hvi K� . Assessors <br />Well Location 459 �//rlLl7�� Cross Street AIAP,4h City / Zip Parcel #OS$–/�D <br />Property <br />Owner C/Ti DF 40& Address City Zip Phone # <br />]� � pq�� � �zs <br />C-57 Contractor Dr Address 950 ,COR1D City 11i%t ine� Zi Lic # / 1 S Phon <br />Consultan Sub Cntr _ TTw 4W4• Address 3 .yCil�l1EJPCSA City /r]Q/¢ A9IYiSLic # N# Phon¢ P 77'_.5 <br />GIS Coordinates. X Tv.l-� Y /LO. 30 / Township _�� 1� ✓ Range E Section <br />W K TOB PERFOR <br />NEW LL/BORIN E PROBE, HYDROPUNCH, HAND -AUGER, OTHER') ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />SOIL BORING# ❑ OVER -BORE DIAMETER <br />❑ WELL # ❑ PRESSURE GROUT _ <br />❑ -OTHER �7 �5 1 GROUT SPECIFICATIONS-- <br />COMMENTS:— <br />PECIFICATIONSCOMMENTS: I Pih� 56 - FST i �DDl2ES5 Al77706n7bh � '/-�-- <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM 1 DIA. OF BOREHOLE A;• ❑ MULTIPLE CASINGS ❑ h1ULTI-LEVEL WELL CASING DIA. <br />❑ EXTRACTION ❑ AIR HAMMER'DRIVEN CASING THICKNESS _ TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ VAPOR❑ M ROTARY DEPTH OF GROUT SEAL _-_— TREMIE TYPE TO BE USED ❑ AUGERS C1 HOSE <br />❑ A SPARGE/020NE PUSH POINT (GP RCPT) GROUT SEAL PUMPED: ❑ Yes [INo (NOTE: MAXIMUM FREE -FALL /DEPTH IS 30') <br />SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 9 �A �Q4 172' S_ Ju <br />� <br />[]OTHER: _ ❑ OTHER: APPROX. BORING DEPTH SD (:1BOLTE RAFFIC BOX OR ❑ STOVE PE <br />CONDUCTOR CASING PROPOSED _ id YES. Ist spo fic funs m mmmant s Cvany <br />COMMENTS <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, I appli a Ca if rni <br />Signed TitlelCDmpany �� Fyt'rtNE€Q /CA/ZLNGINEFR INGi INC <br />��}Cpg e M �`> TH 1=L,IS 71L Date 27 �/) At/ 08 <br />Print Name -- <br />'� (DEPARTMENT USE ONLY <br />i <br />SITE MAP IN UNIT IV FILE. ADDRESS: 1�.*S` I"ov�01w _ <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />DATE I SUED o AREA <br />FINAL INSPECTION BY DATE _C (_ ( 0� <br />DATE <br />COMMENTS/CONDITIONS: 16 BL& ST `� w _ <br />0.1 <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE PE INVOICE <br />sct nJ <br />3 c 8k3 <br />s 4 R# Sa3q <br />C-57 ✓ - WC _— -WAIVER _ C57 LEI I ER OF AU I HUHILAi IUN I U p1(,N YtKN11 I Y______ CNCROAl,nm ClV I Uvi <br />EHD 29-01 11'507 WELL PERMIT APP <br />0 <br />