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SAN JOAQUIN COUNTY <br /> EMIRONMENTAL HEALTH DEPARIVENT SITE <br /> 111110., 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> - Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siclov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <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 /> Well Location dd T14l bf• Cross Street Loxel-)�oa+� Cit r�Qe`I Zi 7 i� Assessor's 21Z-Z30-06 <br /> Property//��, (^ f ,�yD� v.1 y P /��53 Parcel# 4 c� l� /� <br /> Owner C _12i� a CU Address ✓� Yaty U City '1"��C Zip` 533 ID Phone#/ Z� U?Jtl'7�ICJIJ <br /> C-57 Contractor V I tOV)4 InC - Address �ZgZ-Parheco 'Blvd <br /> ` City��Lh EW Lic#�Phonel��5l l'���� <br /> Consultant/Sub Cnt fl h�riVI" W Ad0ress Z3�1- (f- C&-3A C'—'WC•City 11 act] Lic h9l5b i Phone ZA,9, <br /> )ces Inc. <br /> GIS Coordinates:X Y Township Range Section <br /> MRK TO BE PERFORMED: <br /> NE WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDXAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes)<No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING HAND AUGER GROUT SPECIFICATIONS r <br /> El OTHER: El OTHER: APPROX.BORING DEPTH ✓, ❑BOLTED TRAFFIC BOX OR STOVE PIPE <br /> CONDUCTOR CASIN PROPOSED (if Y S,list specifications in comment section) <br /> COMMENTS: ' YI S W <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEM NT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certif at I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a II plicable lifornia aws. ff 1 _n <br /> Signed \ Title/Company �S���T ' T 0 c�l� <br /> Print Name ) hb�a Date 9 8 z 01De' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3q-nd ((' <br /> WORK PLAN DATED: I2 I t0(D <br /> APPLICATION ACCEPTED BY DATE ISSUED O AREA <br /> GROUT INSPECTION BYFINAL INSPECTION BY DATE!� 3o CsK <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 35-0( Sq.ao , 1, Ilk` q 3 0� SR# S`SS,60 <br /> 03 (s•0a' Z(SY <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />