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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 200 <br /> JUN 0 9600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ENujRON E�gp►�Qn <br /> P��M(T/Ste:T#�(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/eh UNIT IV <br /> 4 � EVRfV�AL � <br /> S i WELL PERMIT APPLICATION- <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> fl <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 Assessor's <br /> Well Location Cross Street F. �J a LV_S'Oh St• City �Or TOOY�Zip 5.20 Parcel# <br /> Propertyi / 4i <br /> Owner^l,o..r c�_r✓�vI��S Address f D:f3d* Co ODS City S-fDGkC-tOh zip Sg aob Phone# _7-2J1.2 <br /> ``�� Ji <br /> C-57 Contractor T.Fc-& teary w. Address /(.SSD l�ua 4�A/G P� City Lic#706 hone q/A `.O5.3"PDIQ <br /> Consultant/Sub Cntr JA) efc.evtt�?r Address,//3S2,�1r,,,:Af PK Wac_ CitAA w ("'A /t Lie# Phone q14 <br /> La-f• <br /> GIs Coordinates:lLC 37. 9y.7y3.2, -Township Range Section <br /> KW RK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> `OTHER S'0; I/ . hit GROUT SPECIFICATIONS <br /> I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM ; DIA.OF BOREHOLE !1 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVENCASING THICKNESS TYPE OF CASING:❑STEEL ElPVC ❑ OTHER <br /> ` t i <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> a <br /> ❑AIR SPARGEIOZONE PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes 1"❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS _�V C♦� YY���N L <br /> ❑OTHER: ❑OTHER: APPROX,BORING DEPTHS _ F-1BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTO CASING PROPOSED (if YES,fist specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> :tl <br /> I hereby certify that I have pre ed this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and a licab all ornia Laws. ' <br /> Signed TitlelCompany ax0r:;-r*QZ"6} 45Z�,�/, C_ <br /> Print Is Date <br /> DEPARTMENT11USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 12-a 4- �.CYi 4 S 1' � S�y�`�iDL <br /> FIL E COPY <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED 6 40 AREA <br /> GROUT INSPECTION BY ( u.� [, 1 I� FINAL INSPECTION BY !.l DATE !!f Id9 <br /> fl -rr_7 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> t <br /> i <br /> ACCOUNTING ONLY: AIA# FAC# <br /> PE CODES FEE INFO AMT REMITTED-, CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 35-0 o-'-'00 Zcsrrs 61S61SI&I SR#57 $ <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT �_ENCROACHMENT DOC <br /> EHD 29,01 11/5107(WEB) WELL PERMIT APP <br /> rl <br />