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I ,a SAN JOAQUIN COUNTY F; =� ENVIRONMENTAL HEALTH DEPARTMENTS SITE 600 East Main Street, Stockton, CA 95202-3029 2 8 2409 MITIGATION _ Telephone:(209)468-3449 Fax:(209)468-3433 Web:WOU a lehd UNIT IV WELL PERMIT APPLICATION `�UrCES H NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessors Well Location ItrS O IW.2i;Ihr1 f{..f;. Cross Street '$DIME Pd. city 34408 Iw Zip q.500&_ Parcel Property Owner Haio Si; Address 2q�a.f1 D►: cityWWAl Zip S-APhone# (2tq)q9S-Z11-7�f C-57 Contractor RPjlrlt�i191f tc&i>i nmin€nl fir_Address _8 3'1 3baW W! City 3heJ;ton Zip 45215 t is# G2020'1 Phone-I �� G Consultantl5ub CntrOlja+rK!! �� rfR1 Address R.3'? 4f')aw 1.'c1 City Sftkb" Lic# Bc 20-1 Phone(j J 1411' 10Us GIS Coordinates:X Y Township Range Section WORK TO BE PERFORMED: NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) SOIL BORING# t•tR,)441 l y1,16i1 Hy t,: ❑OVER-BORE DIAMETER V WELL# ❑PRESSURE GROUT ❑*OTHER GROUT SPECIFICATIONS O COMMENTS:-&f eaure a&hm J Sk fl=muz e_w(Wt ma ,r al ed 25-H&C 17 2069 TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ©MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE 1.2,j"_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ f1 ❑EXTRACTION ❑AIR HAMMEWDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER [ ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 30` MAX TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE >4 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ? 'SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS SJ 1 11 W04 b.raii;F ❑OTHER: ❑OTHER: APPROX.BORING DEPTH J ` ' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE Q CONDUCTpR CASING PROPOSED •11, _ _ of YES,list specifications In comment section) COMMENTS: £ t� 1lap, NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS c�J 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS c� I hereby certlfy t I have repare this applic n ertdrth af f�work will be done 1 accordance with San Joaquin County Ordinances,Rules and Regulatlons,a 11 app a fornta vKs ^ Signed TitlelCompany Vice 2 13idwl IMV6711dd(3 , 111RYhl1tr11�t r rt11P. 1 1' i Print Name { d Date DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: a,3 99V W- C/. f�(Suf-rAn %/ate WORK PLAN DATED: APPLICATION ACCEPTED BY ✓FL JA Et3b eAOS O DATE ISSUED Zd a9 AREA �y53 GROUT INSPECTION BY v �gh FINAL.INSPECTION BY_ � _ DATE 010i D DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY PDATE PERMIT/SERVICE# INVOICE aso' 3 3 •1W 3C)0,50 GTR 2 S 09 SR#665'8202 I C-57 WC WAIVER AIIA i C57 LETTER OF AUTHORIZATION TO SIGN PERMIT N ENCROACHMENT DOC I EHD 29-01 11!5107 WELL PERMIT APP a r