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°"'" • SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTAT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 i �;I,MITIGATION <br /> p elephone:(209)468-3449 Fax:(209)468-3433 Web:www.sidov.grgehd'' \` U�1iT IV <br /> 4�/P !-�ORN <br /> WELL PERMIT APPLICATION AUG <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEQf, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicat6k iS.m'ade-ln 66mplfance with San <br /> Joaquin County Development Title, hapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 30ob Lf W. <br /> _ Assessor's <br /> Well Location Cross Street &Uu <br /> City LO t Zip 9 SO��a Parcel# <br /> Property �) <br /> Owner4I`u2�U/lf"� Address i'_._ _ _ _ City—S Zip Phone# _ 'J <br /> C-57 Contractor �f1'L15 on Sc M*, `i Address x365 W,�wm a0C City S4o(,k}on Lic# 636M7Phone(ao9) y65 - 87/a <br /> Consultant/SubCntr West' yos0 Address'&DDJ9 PPA br City IDAyls Lic# Phone CS,36 756- 9_90. <br /> GIS Coordinates:X ,Y ,Township <br /> 3 A Range 5 t Section N <br /> WORK TO BE PERFORMED: <br /> fO NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑ DESTRU T N(CHOOSE TYPE BELOW) <br /> ❑SOIL BOR LN� �]OVER-B DIAMETER <br /> .0 WELL# �V RESSU GROUT <br /> ❑*OTHER ROUT P IFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE �_ ❑MULTIPLE CASINGS 14 MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 10 TYPE OF CASING:❑STEEL IM PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Z a5' TREMIE TYPE TO BE USED❑AUGERS M HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:IN Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING [:1 HAND AUGER GROUT SPECIFICATIONS 3 $/O B GY1TOn t T-L CM014 M,lc <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 applifca�tble alifornia Laws. ZI <br /> Signed �d _�I/ Title/Company I ��r G T OS4 AcSSO L 1 CS <br /> Print Name T)v5�%n L.o, V w1l" Date �o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: j Z7SI <br /> WORK PLAN DATED: � s <br /> APPLICATION ACCEPTED BY /�! � DATE ISSUED �� AREA <br /> GROUT INSPECTION BY FINAL INSPECTION W 12- DATE <br /> DESTRUCTION INSPECTION BY DATE p. / <br /> COMMENTS/CONDITIONS: C UkL,162 L _ ! N & <br /> MS4.0 #lq o- , Dw2— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> S`2-.(:23o SR#, c ssd_F <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIG (PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />