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OPqutk c. SAN JOAQUIN COUNTY <br />Z� ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />ai <br />•., � 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.si9ov.orp/ehd 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. <br />/- n I <br />Assessor's -1 <br />Well Location (X Cross Street LiNcyL-t J City � �� Zip �1S203 Parcel # � T <br />Property W, yv1;590 �; <br />Owner CLT" SToljg me -1 •A`d/dress 42cJ 9. ft DO?iDb ST. City �i�0 N Zip QSQX2 Phone # ( S31- �S� <br />C-57 Contractor C�c�a� b�LUN4ss 3132 Otv<-G CAKLt E City Qililil kl0 (P¢97144 Zip q"_ 2.,Lic # 14 T51-0 Phone (Uj) 63g <br />Consultant/Sub Cntr ':�7Tf t M161 Address 101-4 K.It.(,oGE F—D City �(r,1�0 �-pgo IC # Phone (9Ilei VeI • CAM 1161 <br />T� 1op <br />GIS Coordinates: X 'Y , Township Range LPE Section 10 <br />MIRK TO BE PERFORMED: <br />AID # <br />FAC # <br />JS NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />FEE INFO <br />❑ SOIL BORING# <br />❑ OVER -BORE DIAMETER <br />RECV D BY DATE VOICE <br />j WELL # :EV 'Co?AL, <br />❑ PRESSURE GROUT <br />'OTHER0�1J tC <br />GROUT SPECIFICATIONS <br />, <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS 211 -fqv 4 /. �Lt, TO <br />MONITORING [I HOLLOW STEM <br />U n ti <br />DIA. OF BOREHOLE El MULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS 6U'tED '90 TYPE OF CASING: ❑ STEEL XPVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY <br />DEPTH OF GROUT SEAL 5E1E Ad1AC j0TREMIE TYPE TO BE USED ❑ AUGERS�JHOSE <br />❑ AIR SPARGE/OZONE O PUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPED: Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER <br />GROUT SPECIFICATIONS MAT J✓il1VT <br />I 1 rp lZg <br />1roSt�.`Lfe�C <br />El OTHER: to OTHER: �L, APPROX. BORING DEPTH tZ ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: k w Ayil; � Lwv►ho4(, r anA m6ll <br />be A eA fylllnwiM thG forte r fAk HADD}—ALAI ba&DA 7rat <br />rn l ec !�uJ peaannnn�� Zane <br />NOTE: OFFSITE BORII4GS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />1 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, and all appliccable( California Laws. <br />Signed 1J�— `�` <br />Title/Company 1"JT�i��?�� <br />Print Name <br />Date '73/0$ <br />DEPARTMENT USE ONLY <br />' . 1 <br />Qn <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />0 <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY <br />DATE I SUED % ZY d AREA <br />oB DATEy <br />GROUT INSPECTION BY d <br />FINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV D BY DATE VOICE <br />��o <br />B <br />`7`4`1 1 <br />—Mle� 7 sRl? <br />C-57 WC -WAIVER <br />EHD 29-01 11/5/07 <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT UAGHMEN I U <br />WELL PERMIT APP <br />