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�ANJOACXJtN COUNTY <br /> - - r-NViRONMiEN T AL1- HE�'L T Y Q�Ec).— e`p�_ — <br /> 600 East Main Street, Stockton, <br /> Ca 95202-3029 SITE <br /> Telep'ione: (209)468-3449 Fax: 209)468-3433 Web:www.siqov.orq/ehd <br /> MITIGATION <br /> WELL RERMF APPLICATION - <br /> IIT IV <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 Loca_tion_ �• Cross StreetProperty . tic�r•�' � <br /> City Ct oc Lam, Zip Assessor's <br /> Owner I " Address 2!2ci Parcel# <br /> Ji. City. S'tJ-F- Zip `45Zt Phone# 7�`i.c1ti(� OL <br /> C-57 Contractor �t1,,._ +��r, l �- Address '1� L <br /> City— z Lic# tfcSfLjPhone 'i2S,2,k a q <br /> Consuftant/Sub Cntr�M &I;r, t Address `ic <br /> 1c_,is:�lc` <br /> G15 Coordinates:X •'- itY Lic�,�b �•(37.Phone -3,9'ZK"i-}�� <br /> Y — Township — <br /> WORK TO BE PERFORMED: Range Section <br /> NEW WELL/BORING(CPT�GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER*) <br /> ,C3.SOIL BORING# ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> -WELL# -p,� ❑OVER-BORE DIAMETER <br /> ❑*OTHER ❑PRESSURE GROUT <br /> COMMENTS: <br /> GROUT SPECIFICATIONS <br /> .i,,,•,.,t <br /> h <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION OSS�RUCTION SPECIFICATIONS <br /> 91 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z-4=" <br /> ❑EXTRACTION' ❑AIR HAMMER/DRIVEN CASING THICKNESS ❑MULTIPLE'CASINGS❑MULTI-LEVEL WELL CASING DIA: _ <br /> �, L-jQ <br /> 11 VAPOR TYPE OF CASING:[I STEEL 19 PVC ❑ OTHER (� , <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL , �-+ <br /> � _.TREMIE TYPE TO BE USED❑AUGERS 91 HOSE <br /> ❑AIR SPARGE/OZONE MPUSH POINT(GP OR CPT <br /> GROUT SEAL PUMPED:V Yes ❑No (NOTE:MAXIMUrit, FREE-FALL DEPTH IS 30') <br /> :SOIL BORING ❑HAND AUGER_ GROUT SPECIFICATIONS jYr.,p <br /> ❑OTHER: ®OTHER: stQ 1 <br /> - APPROX.BORING DEPTH <br /> COMMENTS: SS^iaU 9BOLTED TRAFFIC BOX OR <br /> 5 CONDUCTOR CASING PROPOSED ❑STOVE PIPE �. <br /> (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT.P_ERMIT <br /> 48 WORKING HOURS-NOTICE REQUIRED FOR INSPECTIONS— <br /> I <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,an ll applicable California Laws. <br /> Signedr-- <br /> Print Name - --Title/Company ���c�� r <br /> ---.-- Date- <br /> DEPARTMENT <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� <br /> WORK PLAN DATED: 2-o Q <br /> APPLICATION ACCEPTED BY I�/ 0 <br /> DATE ISSUED AREA �` <br /> GROUT INSPECTION BY <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY DATE <br /> DATE <br /> COMMENTS/CONDITIONS: 5 �• 7 <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMT REMITTED CHECK# FAC# <br /> ` f RECV'D BY DATE PERMIT/SERVICE <br /> E- <br /> EHo29-ol <br /> � 7 <br /> ! <br /> (l/ <br /> -WAIVER C57 LETTER SR#6 <br /> TO SIGN?ERMIT v;srp; CROACHMENDOC <br /> WELL PERMIT APP <br />