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eP SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> p i` Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �FOR1� UNIT IV <br /> WELL PERMIT APPLICATION oNs/rE <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED TEI: <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 /> 0i�VE Assessors <br /> Well Location ditV6WAtf'oli Cross Street XWf7- [0041—f1W City lNrHRoi Zip S�?D Parcel# /0/-Y1n-22 <br /> Property <br /> Owner HAR'OfY O A&ffVr KylNgq Address.?;~ Sat LfeRIAW ldAY City rP 4 Zip 11MY Phone#�1P1�J <br /> C-57 Contractor r£G Address//3f0 AfAr R&C CftySAWe4ri ✓ is#�L�BPhone"ft AT?- X*/0 <br /> Consultant/Sub CntrSTANrE/ Address j0/7�/[60,p£ AO4'> Cityr�AHliWo IMAaNVLic# SMfY hone& 8A/-OY00 <br /> GIS Coordinates:X Fi!y Y lam_ Township �y 'Range Section <br /> WORK TO BE PERFORMED: �7-g12 <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 1 iS(1-1 GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS (v/'aq <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ?b ❑MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA:� <br /> Q EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:[ISTEEL ❑PVC JU OTHER NrJW'1V <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> 0 AIR SPARGE/OZONE OPUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ,HAND AUGER GROUT SPECIFICATIONS 1VAe,Fr`o 6 AWMCA.P d[SyrRyir6 <br /> OTHER'.S�'L YARa//4ChQg1 OTHER: APPROX.BORING DEPTH ,S.5� I BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 111aCONDUCTOR CASING PROPO ED 7r� of YES,list weaiiceuonsm comment se r) <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 /> Signedo � Title/Company 641WVAlC PJA-e <br /> BVrrer cCe4le ifdrEG <br /> l,-Am <br /> Print Name r[/lr1�i9,P1> ?xrZ TIE/P Dale <br /> DEPARTMENT USE ONLY �� b <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ���lY"`p�v,{ Y�+�F� ,(' <br /> WORK PLAN DATED: (�3d-t-6 4" 1Q-26'06+ <br /> APPLICATION ACCEPTED BY DATE,ASS D O ' 4RFA ,,E� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATEW <br /> DESTRUCTION INSPECTION BY DATE ���777"���"' <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 5u 6b8� ►� S R# <br /> C-57 e WC If -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br /> EHD 2"l 11/M7 MEB) FILE ` OPAy <br />