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�J L <br /> SAN JOAQUIN COUNTY <br /> `? ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> . 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sictov.org/ehd UNIT IV <br /> q�FORS` <br /> WELL PERMIT APPLICATION KW -bO <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 T San Joaquin County Environmental Health Department. <br /> pp f /� Assessor's <br /> Well Location��l S. F)`P fl 1orCross street S s City Ctt Cev1 Zip gS�3/ Parcel# (93- )yy—/� <br /> Property/� y <br /> Owner /� Address 3ycr �w G.00-1 Citys�.1 g _ Zip9,15 3 Phone#�15—We 5-07/ <br /> C-57 Contractor (� ff l� D/`��`+��1 Address,@0-� d(f /1�,1,�p 936 City t$T (I Lic# t?0 Phone(y'U)3�l-`f <br /> Consultant/Sub CntrShCJe_C Address 301`1 K2ae�e Kd` City B 6gz1r��Lic# Phone (%) <br /> GIS Coordinates:X �j�.g8 / Y t, I• Z6 T Township �7 S Range le�Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW ELUBORSOIL BORING#NG PT,GEOPROBE,HYDROPUNCH,HAND-AUGER) 3�j OVER-BORE DESTRUCTION(CHOOSE TDIAMETERAodezYPE - <br /> f <br /> ❑WELL# RPRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: aJPCJI( W I(C �011) j;017 113,11i,1/1 <br /> l/)/y O <br /> t/ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ 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: Yes ❑No (NOTE:wMA�XIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> Cl OTHER: ❑OTHER: APPROX.BORING DEPTH %2 ❑BOLTED TRAFFIC BOX OR A STOVE PIPE <br /> CONDUCTOR CASING PROPOSED r (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 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed ! Title/Company �S�G✓1�P <br /> Print Name /t/]_(c(J/t/f: Date <br /> //DEPARTMENT USE ONLY�Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: G' 1 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED 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 DATE PERMIT/SERVICE# INVOICE <br /> 0 2 .`ereW—.41-10 R# d <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERMIT ENCROACHMENT DOGJMW <br /> EHD 29-01 11/5/07(WEB) ^ I""i !,';1 j1 �� WELL PE IT APP <br />