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c SAN JOAQUIN COUNTY <br /> _ ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> .rF aN. <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sioov.orG/ehd UNIT IV <br /> WELL PERMIT APPLICATION ofiY/rE <br /> G/A <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 9-1 115.3 and the Stand rdg s of San Joaquin County Environmental Health Department. <br /> ��r/�B C.4*0lY LVr (4 Assessor's <br /> Well Locatii.,. Cross Street !/f19'r lANE City L.lraf0/t Zip 30 Parcel# /t6- f.Po-33 <br /> Property <br /> Owner /11WA01 AW/NDlddress 2WrW -0? 4ArW4lW*Or City T•PAIr_ a Zip fr.1fd9Z Phone <br /> C-57 Contractor W'W Address9.SYV loM,vrrI 93B City I�< CA Lit;#2Af.?R'5�Phonej4e ) 1-107, <br /> Consultant/Sub Cntr ST/,Vr-fC� Addressl0/7K/1�61,0,� rCP "A90 City AL4I YA�O�.fQ Lic# Ys�Phone /6 /'O 00 <br /> GIS Coordinates:X 3�-81/-__ Y -I2l-Lg3 Township Range Section <br /> WORK TO BE PERFORMED: \ <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# :2 CAW-SY AyD Kav-25 ❑PRESSURE GROUT <br /> [I-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> P MONITORING (HOLLOW STEM DIA.OF BOREHOLE 8 ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 2„ <br /> ❑EXTRACTION /❑-AIR HAMMER/DRIVEN CASING THICKNESS S!/ YO TYPE OF CASING:❑STEEL,W PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL .S' TREMIE TYPE TO BE USEDV AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ;(No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS NE.¢T CE,C{,E,yj-- <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 17 KBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED .VO (I YES,list speci(w0om in comment section) <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed xky-4922 Title/Company 6�O<LG/L /'oto jECT J/ oaf[-/ST ST•rTA/rEf <br /> PrintName Ale'y' PO Date <br /> DEPARTMENT USE ONLY 116Q , <br /> SITE MAP IN UNIT IV FILE,ADDRESS /6 <br /> WORK PLAN DATED: 0 Fr !7 0 <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA (/ro <br /> GROUT INSPECTION BY IF FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATf PERMIT/SERVICE# INVOICE <br /> D II #0 56 <br /> C-57 y WC y -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN HERMIT ,y_'�— �.pr�,DD.O�C <br /> EH02aO1 11/5M?(WEB) � I ytl PERM <br /> FILE COPY <br />