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• � ED S O ANJ AQUINCOUN TYN"01 <br /> FILE 0 <br /> ,•.• .o <br /> 2` 1 009 ENVIRONMENTAL HEALTH DEPARTMENT <br /> a' SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �N /H�OH Telephone:(209)468-3449 Fax:(209)468-3433 Web:wvvw.sipov.orp/ehd UNIT IV <br /> p� ' fCES <br /> WELL PERMIT APPLICATION <br /> 5 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 Titl ,chapter 9-1115.3 and the Standards of San Joaquin County*Enviromentalalth Department.� qa�_ 1Assessor's <br /> Well Location�� f � aross Street S f• CityZip kf),3lParcel# A9?a 199 1Propertyif /� H f Phone#(- <br /> OwnerV , ! tr/ /q� ddress / ! CityZip 2�) lF-�C-57 Contractor i��/! Address I T,1 '.n�6,�NIS pt CityLic T Phone�G�3iJ bo�i,1^ 21 /� <br /> Consultant/Sub Cntr���fGtr�'! T�C Address `1�t7 �f7-,.I wdVe City 1liLic# Phone l`7 U 6l 0 <br /> GIS Coordinates:X37,RV 'Y '"I.Z •� T Township Range Section <br /> WORK TO BE PERFORMED: VI <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING,�#x� E.•V-� . ❑OVER-BORE DIAMETER <br /> WELL# �X -t j Atm Ntr, i12S _ !/� ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: /0 j600' iMd� <br /> S <br /> U ©t' r0 P w f • --ww__ Q <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS onn�L f i SAF <br /> it p <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 1.S' _MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA:Aj.W,4� <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC Lj�OTHER 1 E 1 1 <br /> I <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL '`' TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE K PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE•.MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS (_Q/� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment 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 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 alifornia Laws.. <br /> Signed ^� --ITitle/Company <br /> Print NameL1(�� Ry � / e— Date CLI <br /> / <br /> DEPARTMENT <br /> ��USE <br /> ��ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ( i " (. Y/ A <br /> WORK PLAN DATED: V `d <br /> APPLICATION ACCEPTED BY DATE ISSUED 6 G AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DAT9 PERMIT/SERVICE# INVOICE <br /> vq o 1 V. <br /> C-57 wF WC -WAIVER C57 LETTER OF AUTHORIZATION TCSIGN ER IT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) FILE <br /> C PE APP <br />