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SAN JOAP..UIN COUNTY • <br /> (ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 <br /> �J 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.sigoV.org/ehd UNIT IV <br /> • � �IFORN`4 11) � � Lv[u <br /> WELL PERMIT APPLICATION <br /> Vt'r�0�lf�nk�9� HEAtTH <br /> 2,,,,MjjjSER\IIR�9-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. Assessor <br /> 14 <br /> 1 1 <br /> I ` ` yam (( - `,Zea Parcel#o c0-O�-'141J <br /> Well LocaUonD �4�a Ct�c-I(i Cross Street YZ„�"1e.Y' City zip c� <br /> Propsrt �Owner 0 Address dZ L. City q <br /> 7Zip Phonoer# <br /> C-57 Contractor dress .J(O V, IC„ City 01Alh1 ' <br /> e- 3t~7 <br /> 4ZS al -0 � <br /> Consultant/Sub Cntr . Address 1A(44a '22L°U5i1L.2-.City Le# Phone t A:v <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLJBORING(C T, EOPP OBE HYDROPUNCH HAND- UGER OTHER' ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#�t-4� 99 - S'('J� 4s'f S -�1� spa, O ❑OVER-BORE DIAMETER <br /> ( WELL# �Q\ Vh I -t 'r VYl LLQ—�1� ❑PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING RHOLLOW STEM DIA.OF BOREHOLE I' �`� `!^�MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESSSL(A 111) TYPE OF CASING:❑STEEL [XPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL '�?" / TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:C9 Yes ❑No ((NOTE:MAXIMUM <br /> IFREE-FALL DEPTH IS 30') <br /> EI SOIL BORING [IHANDAUGER GROUT SPECIFICATIONS �nV'1 l CMS Ck <br /> Cl OTHER: ❑OTHER: APPROX.BORING DEPTH '7'O * ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES.list spi in a enls 0,.n) <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. //__ ( y., (� <br /> if <br /> Signed n `� <br /> p_T1Jl.l.l � � b Title/Company (� I��ID 1 <br /> Print Name g,'1 1i VL4 r h 1 i(A S Date " 0%-t <br /> DEPARTMENT USE ONLY FILE COP Y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 13e ir. <br /> WORK PLAN DATED: �- 2Ts �SZ-G�'t'�''u u' <br /> APPLICATION ACCEPTED BY ( (�-n e- DATE ISSUED -3"/2-V./f0 AREA <br /> GROUT INSPECTION BY _ � A i^_�_ Io�..1 ��� FINAL INSPECTION BYnw�lnlr'1A/\ DATE O J3 IC <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES JFEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> 35 0 gq.ot> 203 {2 GQ 4 Pitto I SR# OS` S <br /> C-57 WC -WAIVER C51 LETTER OF AUTHORIZATION TO SIGN PERMIT 4-� _ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 10/28/09 <br />