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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.pigov.orglphd <br /> <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <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 arid/or Install the work described. This application is made in compliance with San <br />Joaquin County Development Title, chapter 9- 115.3 and the Standards of San Joaquin County Environmental Health Department. <br />-oulAJEL, 44 0 tk,i aftwowA.,L,z." Assessor's <br />Well Location 1 Z35 91AvrA•kv. P-t4 Cross Stree H nA Er City 5 +0 CP.:, Zip Parcel 114r7 7 • 'MO - <br />Property <br />Owner t.e.1) cal, fe. yvc+ Address f'4, ay./. i4 City tAAO819i: Zip 475258 Phone # (Z 01)367- 60”'?._ <br />C-57 Contractor Address 07, 91b City Zip °I 5 2 Lic '7 •0 Toy phoifitq %ea <br />te/Gi <br />ConsultantISub Cntr $ Address 11! -I +a4g City E S C 1.4 I InA Licif Phone (10568-if,- -7e-6-er <br />GIS Coordinates: X Y , Township Range Section <br />WORK TO BE PERFORMED: <br />aNEW WELUBORING (CPT. GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') 0 DESTRUCTION (CHOOSE TYPE BELOW) <br />El SOIL BORING# El OVER-BORE DIAMETER <br />E WELL # itt\tO ' 1 EI PRESSURE GROUT <br />El *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />0 PUSH POINT (GP OR OPTL. <br />TYPE OF WELL <br />INSTALLATION TYPE <br />Ea MONITORING 'HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER!URIVEN <br />1:1 VAPOR <br /> <br />0 MUD ROTARY <br />12 AIR SPARSE/OZONE <br />o SOIL BORING <br />El OTHER: <br />COMMENTS:Atkol 1/ '1"D c.L itta> <br />CONSTRUCTION SPECIFICATIONS <br />DIA, OF BOREHOLE g " 0 MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA. <br />CASING I HICKNESS e-> , LI 0 TYPE OF CASING: El STEEL TR PVC 0 OTHER <br /> DEPTH OF GROUT SEAL -2- TREMIE TYPE TO BE USED 1:1 AUGERS El HOSE <br />GROUT SEAL PUMPED: Fa YoeQ NO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br />GROUT SPECII-ICKI IONS /I)C4t4" e 4- <br />APPROX, BORING DEPTH SO BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED et YES, list speck:Mims in comment section) <br />0 OTHER: <br />0 HAND AUGER <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 applicable California Laws. <br />Signed )"{_. Nov <br />Print Name 3 -\14e) v•e- <br />Title/Company 'YEN 6.--C 61O f 1 d 're/0 4„/y ,,•t- <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN LAT IV FILE, ADDRESS: Cif )442444/44.^-, <br />WORK PLAN DATED:___ <br />APPLICATION ACCEPTED BY 4/10 <br />GROUT INSPECTION BY <br />DATE ISSUED &Ai AREA 9g <br />FINAL INSPECTION sy 1,2 DATE 7 a <br />DESTRUCTION INSPECTION BY <br /> <br />DATE <br /> <br />COMMENTS/CONDITIONS: LOP SM.', fiRy <br /> <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK 4 RECV'D BY DATE INVOICE <br />3C0 <br />C-57 , WC <br /> <br />WAIVER <br /> <br />057 LETTER OF AUTHORIZATION TO SIGN PERMIT NCROACHMENT C <br /> <br />END 29.61 1115T7 wELLPEaror AYP