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'P°`'"" SAN JOAQUIN COUNTY <br />/o' c % <br />lr r Z'; ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sipov.orq/ehd <br />R% 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 />Assessor's <br />Well Location / �S�f f� E/vU. Cross Street I(fCkLf (N (l. iA i City S %yCkl-0 A) Zip�S �p r Parcel # t 1 q [ QO �S <br />Propert/M /� 12 <br />Ownerl-A SL lA UI- t e"Q/ICriOA Address 2-201 W, t4) I.f 1A City S%Z'GC�Z A) Zip Yo'? 6-? Phone # 207 44, 0-17 <br />C-57 Contractor FAQ -044-VAddress �9q-4/L-PLA6 City _y_Q&4 Ci Ty Zip 159q ./Lic# 6 q46 Phone <br />Consultant/Sub Cntr _,2 e- &L_1j ) So& Address IC -90 .%C4/00 (U+y tt- A City &)tUCn1-_8 Lic # Phone �� a,60 3/, <br />GIS Coordinates: X Y 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# S ❑ OVER -BORE DIAMETER <br />❑ WELL # ❑ PRESSURE GROUT <br />❑*OTHER GROUT SPECIFICATIONS <br />S <br />COMMENTS: '.,OIL. tj3n-k1&4S --0-TAt, (3) 9FF1 VE �eiA;,,S M" 9C- Ccwv' 2/�t�N1-tD&I <br />TYPE OF WELL <br />0 MONITORING <br />❑ EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />® SOIL BORING <br />❑ OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �j <br />❑ HOLLOW STEM DIA. OF BOREHOLE ��f ❑ MULTIPLE CASINGS [3MULTI-LEVELWELL CASING DIA:�^It <br />ElAIR HAMMER/DRIVEN CASING THICKNESS SC//}}H 40 TYPE OF CASING: [I STEEL 0 PVC [I OTHER <br />❑ MUD ROTARY DEPTH OF GROUT SEA Kt ) J b5TREMIE TYPE TO BE USED ElAUGERS Sd HOSE <br />❑ PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: P1 Yes ❑ No (N TOE. MAX�III iUM, FREE -FALL DEPTH IS 30') <br />❑ HAND AUGER GROUT SPECIFICATIONS` C-FiI�W-V t T- ,. 9 <br />_ -.. <br />OTHER: SOtjIC, APPROX. BORING DEPTH 19 BOLTED RRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED if YESWspecifications 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, and/all appl/icable C 1'fornia Laws. �� ,, <br />Signed I�� /� Title/Company 1G�1.)S ��5�. — `� �6"— <br />PrintName vU, leiCk- 4fACKF_-- Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: to o -iIL- I-Ifla o <br />APPLICATION ACCEPTED BY i�r1.i h..- r �— DATE ISSUED -L D sS AREA <br />If I <br />GROUT INSPECTION BY 1 AA1,C Gtl, 6 t �-'—(C,-6­ FINAL INSPECTION BY DATE 6yktLOk <br />DESTRUCTION INSPECTION BY <br />COMM ENTS/CO NDITIONS: <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 />PERMIT/SERVICE # <br />INVOICE <br />as -o► <br />So 3 <br />�-t.0o <br />,4'I 79 • oc, <br />s6iots <br />ttQR# <br />b z 0 SrFf <br />S Z3 <br />C-57 / WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC &1A <br />END 29-01 11/5107 WELL PERMI <br />