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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION •c'� �... ... �D 09) 468-3449 Fax:(209) 468-3433 Web:www.s'gov.org/ehd � UNIT IV ��ppnnQQ__ WELL PERMIT APPLICATION SEP ® 3 P9fi3P0%EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is herebY�� C n r a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County DeveTo / �� T and the Standards of San Joaquin County Environmental Health Department. n f q Assessor's Well Location�CDv��S�Qv` Cross Street S ?Ove�Oo+oo City`S�t¢.1� Zip =1�L!I Parcel#_/-1•goSOS_Z Property Owner__ — _ BAddress 31 E_ ---- - }_ --- — ----_-_-- Zip -----Phone Soq__ _ a # ci?_T4- - SS Q�c7� Ave Cit W �a � Lic# 6610 Phoneqr� t -1C-57 Contractor r�x,�4Cf4= Address� LJ ---_ ------G O Consultant/Sub / Cntr Address___________________________ City --------------- Lic#---__-__Phone____—_ GIS Coordinates:X ------------------ ,Y -______-_-___-_-__,Township __-_--_-_--___ ___-- Range------——-- Section --------- WORK -_-_-_- WORK TO BE PERFORMED: >(NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") ❑DESTRUCTION (CHOOSE TYPE BELOW) SOIL BORING# othchx,�eDl�w �Ick__ ❑OVER-BORE DIAMETER___________—__ WELL# _-1 borS__ _[ 1V oLr� _r-vo-k�r4�y txi�EC( ❑PRESSURE GROUT ------------- ___----_-_ ❑*OTHER �_ - ___________________U GROUT SPECIFICATIONS -------------------- COMMENTS: ___—_--___-___ _COMMENTS: —--------- TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS er 1 u MONITORING HOLLOW STEM DIA.OF BOREHOLE SCCS,_,,_'' ElMULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:gt El EXTRACTION 1-1 AIR HAMMER/DRIVEN CASING THICKNESS J 11 6 TYPE OF CASING:❑STEEL WVC ❑ OTHER ❑VAPOR ' MUD ROTARY DEPTH OF GROUT SEAL _C.f-0______TREMIE TYPE TO BE USED MAUGERS El HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)----- GROUT SEAL PUMPED:%Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS _________________--____ I ❑OTHER: ❑OTHER: -------------------- APPROX.BORING DEPTH _(cc) ____ ❑BOLTED TRAFFIC BOX OR El STOVE PIPE CONDUCTOR CASING PROPOSED ------------ (if YES,list specifications in comment section) COMMENTS: NOTE: OFFSITE BO REQUIRE ACCESS AGREEMENT OR ENCROA ENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and all applicable California Laws. (� L Signed If__- ---__ Title/Company 1_r0� i1��C' ! vt_�) t liS . ----------- ----- �- ---- UU---- Print Name - _ -____ ate—Q4�8 I DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: __ZC S'c�G_lj�_L� �_�� _�A_r��Z �i �_ __ ��1. >L�NG�1��L SA-J WORK PLAN DATED:__ 9-------------- ----------------- - ---------I----/ ��-------- �GLIti1G APPLICATION ACCEPTED BY __ �ldC� �I_____________ DATE ISSUED _ _Ll1 ___ AREA _ GROUT INSPECTION BY ��1 [[iy�___OL1_2�j - --_ FINAL INSPECTION BY �Jp / —/// DATE DESTRUCTION INSPECTION BY _ ____ DATE_---------------- _ _ COMMENTS/CONDITIONS: os 3 6� 1—______—__-______--_-- -- - — --------- 6 L ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE ZIP 5 (,1Q °t 16 SR# 5$3L/8' WC _ WAIVER _ C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC------- EHD 29-01 11/5/07(WEB) WELL PERMIT APP