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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> > 600 East Main Street,Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ``gi:(F.:`•a� 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 Departmenl <br /> L�- <br /> Well Location;ct Lt I C/d Pr- Cross Street (kLtir � <br /> city c6T7ln Assessors <br /> Property zip q 5,XO6 Parcel# I1-030I0-� <br /> c <br /> Owner Iry rj �� J�A�Eyn Address /I City Zip Phone# <br /> C-57 Contractor �j�DC- Address C(5'80W <br /> 80 Co�� �CI City ZOMII Orti _ Zipzi a Llc# 283326 Phone <br /> Consultant/SubCntr Ct�lr'` Address_3015 SO Is+.ky,,e- City ?017 b �r OR Llc# Phone 503-Rd 4.Yro cp <br /> GIS coordinates:X3 `S6/4-03�N Y QV Lal SZ-Z4`(,J ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) I-]DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# [I OVER-BORE DIAMETER <br /> C�3 WELL 4 2, ❑PRESSURE GROUT <br /> ❑ <br /> 'OTHER GROUT SPEC]F ICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE <br /> MULTIPLE CASINOS El MULTI-LEVEL WELL CASING DIA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS S JA Ik Cit TYPE OF CASING.❑STEEL&VC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL k4J%-(At_ TREMIE TYPE TO BE USED GAUGERS[;HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:jg Yes ❑No(NO/TE:MAXIMUM FREE-FALL DEPTH IS 30% <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIF ICATI DNS n6.,k f GQ_l i& <br /> ❑OTHER OTHER. J8 N Cc _ APPROX BORING DEPTH ,M-BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING PROPOSED lir YES.list specifications in commanl section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify t t I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatio d II appli b Calife� ornia Laws. 1 � 1 /A� <br /> Signed C� �_ Tille/Company n Qc�l mc-Ax � <br /> Print Name CIS k-,A 6rc QJ t ____Date oZ 6v <br /> q'` M DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED7Mil <br /> d AREA7? <br /> GROUT INSPECTION BY FINAL INSPECTION BY AW/µ-O`� DATE/JV <br /> G <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS; ­&ATrG aA-Q,— <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODESFEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> (� D O ( 59- Ccs 6 (o y I /� ? ! b SR#bl) 9? <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER JIT ENCROACHMENT DOC <br /> EHD 29-01 1008108 Wt LL PERMIT APP <br />