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SAN JOAQUIN COUNTY <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.siaov.oro/ehd UNIT IV <br /> Ya 6� <br /> WELL PERMIT APPLICATION orFrrr� <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 /> '111i ,,,,,c. Assessors <br /> Well Locations �LYLo eow ross Street !/66/' [,rWB City C./rYCOP Zip 91130 Parcel# Y3o 33 <br /> Property <br /> ownerAddress 2101041' fo• 41 WAr City rfAi e4 Zip 4$o Y Phone# 40 .91111 <br /> C-67 Contractor TEd Address //SSD 44t//ER jili P!/ICE CityA/�� e4beO&Ofic#7 LBSPhone JJW 65�-619/0 <br /> Consultant/Sub Cntr lr4AW6-G Addresli k'4'6ili TOAD Ali Cityle Dc 11`Sy J hone AW ds�'-OVCV <br /> GIS Coordinates:X_ 3T•&I� _ ,V —I?-I .283 -Township Range Section <br /> WORK 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 S✓^S rN.tr/ Sr/—Y GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rr <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE _A ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: N <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL O PVCA OTHER dryL DIV U- <br /> i <br /> [3 VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL •.S 7ftEMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE Q PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes J9 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING HAND AUGER GROUT SPECIFICATIONS d1?7.4IPfi 1%;0F ~,e AX4"-AV--M' <br /> aa P'ADM P4A* <br /> OTHER: sOTHER: APPROX.BORING DEPTH S S BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUC <br /> CONDUCTOR CASING PROPOSED Ate— OI YES,list specifications in mmmeni sac4onl <br /> COMMENTS: <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 1 accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and/all applicable California <br /> CC��ali��fornia Laws. <br /> Signed "—�Y �[�./ll!/ Title/Company "Pro /e AAP-ri GT jPCanyt/tT�rA/.VIEG <br /> I <br /> Print Name /i r/E,e Dater <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ��r 7-10 Cp � <br /> WORK PLAN DATED: 30 f QC;;— .7,0 r a <br /> APPLICATION ACCEPTED BY DATE ISSU '"S�8 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE11 Op <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID If FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DAIE PERMIT/SERVICE# I INVOICE <br /> d J S$ 5* 1 t� 2 R#D5(np57 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT EDICR6AfY1NIERT DOC <br /> EHD R&et 11I5107IWEBI �u/I���M'PMc P Y <br />