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SAN .JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />". SITE <br />�.! 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />P Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.siclov.ora/ehd UNIT IV <br />.l, j i+•nNf <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 />-1, I Assessors <br />Well Location 1533 ���gd til - Cross Street W LC�ittIM4A_. LA. • City � Zipq5mo Parcel #QqS- I4 -0O � <br />Properh } n- nn ��-�� I <br />Owner 1vtrrL} KWG/ IaA�✓Lt Address rrr rv_ Woed/ Dr. �i(►pp+� 1 ZiP�,2 2f�Phone# I b e <br />C-57 Contracto VV Address �q7 L �M� Ll f. CityQ� ��py Lic #�Q PhoneQQ�y, `� p ,')(? <br />Consultant/Sub Cntr Address ' New Dr, �, � City � _ Lic # Phone /I L . I%S. Z0 -j9 <br />GIS Coordinates: X Y <br />Township Range Section <br />WORK TO BE PERFORMED: <br />PE CODES FEE INFO <br />❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) 54 DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# <br />OVER -BORE DIAMETER <br />❑ WELL # <br />❑ *OTHER <br />W PRESSURE GROUT <br />INVOICE <br />GROUT SPECIFICATIO�- 6tes4nw jj e <br />COMMENTS:^W 11A <br />JN e <br />a6 <br />I - <br />SR# -0054 <br />� <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW STEM <br />DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _ <br />❑ EXTRACTION ❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS __ TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ VAPOR ❑ MUD ROTARY <br />DEPTH OF GROUT SEAL __ TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT) <br />GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 3(r) <br />❑ SOIL BORING ❑ HAND AUGER <br />GROUT SPECIFICATIONS <br />❑ OTHER: _ ❑ OTHER: <br />APPROX. BORING DEPTH_ C1BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />COMMENTS: <br />CONDUCTOR CASING PROPOSED (if YES, fist spKftatlons in comment section) <br />—" --` <br />NOTE: OFFSITE BORINGS 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 applicable Ctitplrn <br />Signed C <br />// f <br />TitlelCompany <br />K <br />Print Name c1 • W&L(, <br />Date <br />DEPARTMENT <br />USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS/ /A/' <br />CA644-& <br />WORK PLAN DATED tfl / 41 UV IV // SG <br />APPLICATION ACCEPTED BY DATE ISSUED /Ip6-7 <br />6 AREA <br />GROUT INSPECTION BY FINAL INSP CTIOh BY DATE W05 <br />DESTRUCTION INSPECTION BY DATE <br />7 — -f— <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY <br />AID # <br />FAC # <br />PE CODES FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'O BY <br />DATE <br />PERMITISERVICE # <br />INVOICE <br />oZ <br />036 79 o <br />a6 <br />// °1 <br />SR# -0054 <br />nrvLrn _ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />E110 29-01 1115107 (WEB) <br />ENCROACHMENT DOC <br />WELL PERMIT APP <br />S <br />