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C� ,ECE�V\f���NVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> T one: (209) 468-3449 Fax:(209)468-3433 Web:www.s'gov.org/ehd UNIT IV <br /> MAY 01 16�' <br /> ENVIRONMENT HEALTH WELL PERMIT APPLICATION 'Z„ crt�r <br /> RERMIT/SERVICESN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t)to"/Q`RII, <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 /> �[� D• NoH j,� �^ Assessor' ry 5 01 O_p 2— <br /> Well LocationVOF �Q _BLBC�KV}' Cross Street C NV City I �aC Zip 9 Parcel# �✓ '� _ Q,.- <br /> Owner 1 . Address (� �� S y City Property Zip �/'Phone# G J <br /> C-57 Contractor SZ Address 220 r S`1 • City m Zip95 J ��Lic#602334/ Phone✓ 2*24 <br /> Consultant/Sub CnttrJr tjeDj^V(�t,1/(�� )C Address:UQ I.I�J•/CiW r J�• '` Oty 1�1a�� Lic# PhoneS1O^lVb3 7MIP7 <br /> GIS Coordinates:VIZI•�3 7 UIWO�Y ��• �� , `1ON Township :2— SDV4�A- Range Section 2� <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) DESTRUCTION(CHOOSE TYPE BELOW) 11 <br /> ❑SOIL BORING# VER-BORE DIAMETER <br /> �FWELL# _ I C PRESSURE GROUT <br /> `OTHER --� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 2-11MONITORING HOLLOW STEM DIA.OF BOREHOLE •11of[I MULTIPLE CASINGS[-]MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS S!M �" TYPE OF CASING:❑STEEL*VC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL __ TREMIE TYPE 10 BE USED KAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes�QMNo (NOTES:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING E]HAND AUGER GROUT SPECIFICATIONS [ Neu- PD <br /> 1 ' 1 <br /> APPROX.BORING DEPTH I XBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ❑OTHER: ❑OTHER: if YES,lists e ications•incomme f—, /I <br /> CONDUCTOR CASING PROPOSED � ( P � <br /> COMMENTS: In <br /> — ' <br /> L 0vj <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 2 <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,R�uulles�and <br /> Regulations,Utlu <br /> applicable California Laws. <br /> %litick <br /> Signed � Ap_n t�V�"' ��/f '� Title/Company <br /> Print Name '�/`/'C P �� `'r�� Date 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: g0'l� 9" � >/ <br /> WORK PLAN DATED: -3o'0 <br /> APPLICATION ACCEPTED B!BY <br /> DATE ISSUED S' S AREA <br /> GROUT INSPECTION BY d <br /> FINAL INSP CT ON BlM "' LETS DATE <br /> _ / <br /> DESTRUCTION INSPECTION DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 290 L wtD bb. 3 6 .�'`I -$ R#05 !g <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROAC MINT DOC <br /> EHD 29-01 11/5/07 WELL PER APP <br />