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"`"SAN JOAQUIN COUNTY <br />4, t <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />k, ow 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sa.gov.org/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 />I Assessors <br />Well Locatior>L 4 �,ti�its�. L'L- Cross Street tCaSIL1 � City �_ Zip Parcel#( Z- 02-(`�5_ <br />owner �� Address,29 W -.V-Ste Cdy1�M1V� Zip f 2j, 3 Phone # <br />C-57Contracto ('Address -%3 (_'t r-. ��p <br />. CityFr Lic#il%Qi0 Phoneg16, X.1(49 <br />Consultant/SubCntr �� Address fj' an kr.Stk. city rM I Lq&L Li"$IPhone ?1(y,AS. 2A%f1 <br />GIS Coordinates X <br />, Township <br />Range Section <br />WORK TO BE PERFORMED: <br />❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ESTRUCTION (CHOOSE TYPE BELOW) <br />ElDSOIL BORING# OVER -BORE DIAMETER /L <br />❑ WELL # _ PRESSURE GROUT <br />F1 *OTHER GROUT SPECIFICATIONS [tMe.t4— ,EA,'I1.Zyy,,� <br />COMMENT -l05 -/O� - 7 VY'Q WNR 'yVaa' <br />6 . O Q <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS bt;%I--IfiL cb06,0 j atm• Hw 01th" Sw64ct <br />❑ MONITORING ❑ HOLLOW STEM OLA. 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 SPARGEIOZONF ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HANO AUGER GROUT SPECIFICATIONS <br />❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH i ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED __-__ (W YES, fist apecNcstion in wmmmt section) <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 I have prepared this VpjirAUpn and that the work will be done 1 accordance with San Joaquin County Ordinances, Rules and <br />Regulations and all applica fo a `_ <br />Signed �_ Title/Comcpany [moi./A&M S <br />Print Name _ Z.Z._ __ kAA t L— _-_ _ Date %2 • C <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED 3C1 [/- <br />APPLICATION ACCEPTED BY DATE ISSUED p p L/ d AREA /; % <br />GROUT INSPECTION BY _ FINAL INSRECT14N BY <br />� �DATE q"Oq <br />DESTRUCTION INSPECTION BY DATE 0 / <br />COMM E NTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV D BY DATE <br />PERMIT/SERVICE # <br />INVOICE <br />Id 6� <br />!0 o <br />D 3 ? ogL/I <br />SR# 4af(. 8 <br />C-57 WC -WAIVER C57 LETTER OF AUTHORI TION TO SIGN PERMIT <br />EHD2901 11/W7(WE8) <br />ENCROACHMENT DOC <br />WELL PERMIT APP <br />