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SAN JOAQUIN COUNTY <br />!;Kil ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />Af,! 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />jw. Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br />9 N / <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 />22,'' 1 'W �I Assessors <br />Well Locationi7t�1 eMGk LA. Cross Street 5 Flct:sakti A'e— City ,� Zip ?SL -1 O Parcel #Q4$ -14-002 <br />Proparh• n/�y`_ �`--_ <br />Owner' ye,� 4- r1tCX 601-. Address ttlS 1:Jf01110 �r, City Ludt Zip%7440 Phorle ## <br />Lj <br />C -til Contracto JJ 41 Address 3 Z OMxc Lr. City9 "a. Lic #-? 175 Phone I((�, &St . 1/1, Cy <br />ConsukanVSubCntr Addresai2fi&w %C S , ! s City 'FGISV,1 Lic# Phone T6, its'. U ll <br />GIS Coordinates: X <br />Township <br />Range __ Section <br />WORK TO BE PERFORMED: <br />❑ NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) WDESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ,l -OVER -BORE DIAMETER rr <br />❑ WELL # $[PRESSURE GROUT we <br />❑ 'OTHER `` 1L� GROUT SPECIFICATIONS f L <br />COMMENTS: GX-1 4e 'k14d 'N d �N h D a t +r .+ -C rbalt, p1r., e.s <br />r 1p 'll_2t' 41 "-t�-3+ v-tl-sl-;r_`i <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS '�tiv fit ,a� est Cr raw. la w. 'Ta ivrFAw <br />❑ MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION <br />❑ VAPOR <br />O AIR SPARGE/OZONE <br />❑ SOIL BORING <br />❑ OTHER: <br />Cl AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ HAND AUGER _ GROUT SPECIFICATIONS <br />.._ ❑ OTHER: APPROX- BORING DEPTH ❑ BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED - (it YES, hal speC7hwlons in oomm*M 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 />Regulation and all a able C a <br />h <br />Signed Title/Company a a S <br />Print Name �. W kL1 _ - Date <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: ///� j/D�, G{�Qi(/►�I(/ <br />APPLICATION ACCEPTED BY �` DATE ISSUED gfil'1405 AREA q ti 7 <br />GROUT INSPECTION BY FINAL INSP CTIO BY IL�-""- DATE <br />DESTRUCTION INSPECTION BY DATE _I 09 <br />COMMENTS/CONDITIONS: <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/8ERVICE # <br />INVOICE <br />'F- <br />C <br />WC -_--WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br />£HD 29 C 1 11/5107 (WEB) <br />ENCROACHMENT DOC <br />WELL PERWT APP <br />