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ooaUIN: SAN JOAQUIN COUNTY <br />G� ENVIRONMENTAL HEALTH DEPARTMENT <br />SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />c P Telephone: (2q9 468-3449 Fax: (209) 468-3433 Web: www.sigov.orq/ehd UNIT IV <br />?�,FORN` Gall -kir cnspec%Ton : 953--7(,j 7 are -A codc <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 />ppL Assessor's <br />Well Location, .►w JOdOuiM �iJtP� �`D41Cross Street Mww' w at NoILL Ap* City n Zip 85231 Parcel # <br />Property n p n �1 r p Q,�(�4f(1 �" (,� [aQ <br />Owner xmg � KY �T0 i L ll Address 23rS�C.rrll�4,blppf AVE i.0�y-City 1 S1f"kon Zip u� ' I 'Phone ## 21- 445' SSI <br />p3 <br />C-57 Contractor G�� ly%- SAIA Address 950 MWe• f a&A City Aw4;KG2 Zip 97 S55 Lic # !J� ,5165 Phone <br />Consultant/Sub Cntr ,Address 100D to&AwA�Wie" i%ity 0aklarA Lic#1Q=Phone S(O-269- 0441 <br />0 <br />GIS Coordinates: X IZI.3Z�49" 'y 37. qZ6$ tJ Township Range Section <br />WORK TO BE PERFORMED: <br />❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") ) (DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />❑ WELL # XPRESSURE GROUT i %C <br />❑'OTHER GROUT SPECIFICATIONS b <br />COMMENTS: <br />C' <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL )<PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ` <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER <br />❑ OTHER: <br />COMMENTS <br />❑ OTHER: <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <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 this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, an II applicable forpip Law(� <br />Signed ' Title/Company pojk`cT UniLrllJEe(LZFUcrw OE -Si <br />Print Name RN` L-(t1J J WAuj,2(L- Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATE <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DEPARTMENT USE ONLY <br />DATE ISSUED <br />FINAL INSPECTION BY <br />DESTRUCTION INSPECTIONBY ��� '!'2rllin _f DATE <br />COMMENTS/CONDITIONS: <br />..AREA Z <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />P ERVICE # INV <br />SR# �1g3 <br />C-57 WC -WAIVER <br />EHD 29-01 11/5/07 <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />