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�a�+¢V.�'�..� �~ SAN aO4QUIN COUNTY I '" COPY <br /> ENVIRONMENTAL"HEALTH.DEPARTMENT SITE n <br /> y . ._ 600 East Main Street. Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209).468-3454-Fax:(209)46873433 Web:ww�w,s'go_v_.Orgrehd UNIT IV <br /> CjeO � <br /> WELL;PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED f <br /> Application is hereby madtE o San Joaquin County fora 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 Heailh Department: , <br /> e " Assessor's <br /> Well Location Lteaq � 11�tLLo4r 1�Cross Street Zipctg W'C "Parcel# I4I4,t44* <br /> Prope <br /> Owner k 1&UUXA5 Address. 61 tAdir vt'k City fC> Zip9tiog Phone li*) r —%W <br /> C-57 Contracto ddressE4(O�P a k' Cily d ipq�[Jft Li, 00�Tj_Phone <br /> ConsultanU OMaYDI MAIMINddress4%��0t`uA*O61i �T• 5 City AD4%13t-rLic#1 hon,&66 _-1 <br /> t � , <br /> GIS Coordinates:X' 'Y-12�.. 1 Township ,+`� Range tc 5 Section 44 _ <br /> WORK TO BE PERFORMED: <br /> '❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(CHOOSE TYPE BELOW} <br /> El SOIL BORING# O21 <br /> VA R-BORE DIAMETER L <br /> ❑WELL# PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS M e <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: t <br /> TY E OF WELL _ i "INSTALLATION TYPECONSTRUCTIONSPECIFICATIONS <br /> v\ <br /> MONITORING KHOi_LOW STEM bIA.OF:BOREHOLE � ❑MULTIPLE CA"SINGS❑MULTI"LEVET WELL CASING pIR: <br /> ..: .t <br /> D EXTRACTION � � ❑AIR HAMMER/DRIVEN 1CASING THICKNE=SS�'YV"TYPE OF CASING:El STEEL KPVC C] OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREIvlIE TYPE TO BE 11SCD❑AUGERS❑HOSE # , <br /> ❑.AIR SPARPFJOZONE - ,l]PUSH POMT(GF OR CPT),_____ GROUT SEAL PUMPED'❑Yes ❑No(NOTE: MAXIMUM FREE-FALL DEPTH IS 301j <br /> ❑SOIL BORING F' ❑HANE]AUGER k' '!GROUT SPECIFICATIONS <br /> — Jll�01vf M W"� Z 7j W-e r,CGt�t--'APP�PR3OX`.BORING D�E'PTH 0 (12S4Wi4. iY❑BOLTED TRAFFIC <br /> FFIC BO�JX -OR ❑STOVE PIPEOTHER: DTH liCONOUG2'vR C G PRq0';FD (i1 YE liNeatVcom -0n) <br /> COMMENTS' <br /> .i <br /> NOTE: OFFSITE BORINGS REQUIRE'ACCESS-AGREEMENT OR ENCROACHMENT PERMITS 1. <br /> r. AB WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify tha have prepared this application and that'the work°will be done].accordance with San Joaquin County Ordinances,Rules and a <br /> Regulations,and al ppl€cable f ni Laws. p �: <br /> Stgnsd ?? Title/Company <br /> iif� �1dAD « �tQ Ott ��slt+r;�tiwevd��J <br /> Print Name l� w�i • Date 2 Ip <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> PI t 4 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY r AREA <br /> S <br /> GROUT INSPECTION BY FINAL IN PECTIO DATE;j:: <br /> DESTRUCTION INSPECTION BY PATE* "S i{ 1 7I <br /> t <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# _ <br /> PE CODES. FEE INFO AMT REMITTED CHECK RECV'D BY DAT PERMIT/SERVICE# INVOICE <br /> ru AA <br /> G 57 WC WAIVER C 7 LE Eft D AUTHORIZATION TO SIGN PE Mf ENCRO CHMENT DOC <br /> EHD 29.01 10128/09 WELL PERMIT APP <br />