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:I <br /> k� <br /> oPq .n••, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> r _ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> nPlephone: (209) 46&3454 Fax: (209) 468-3433 Web: www.sigov.ora/ehd UNIT IV <br /> �IFp <br /> ENVIRONMENT HEALTH <br /> WELL PERMIT APPLICATION <br /> PERMIT/SERVICES 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 <br /> � of San <br /> Joaquin County Environmental Health Department. <br /> , � � R`SC ^T I/ t" city S'btr,- , r� Zip Assessors <br /> Well Location `�) � 5 . S1• o ross Street La V\ O• \�$ Ci 4SZnb Parcel # I (e3 6O - 1LV <br /> Property YI1 � Zi <br /> Owner a .(3 <br /> loud reS Address � 8( 7 5 �yo <br /> /. no eNga11' City 5SAT � p� '7 <br /> Phone # -o9 - 9SI - 12>S3 <br /> C57 Contractor %� e IPV, E• �. S. Address 2/{'7C, \2WYS bV j r1 Y'ecity P; • &Lm Zip ILK�0I Lic # 61gtA l Phone <br /> ` s to S,101059 <br /> Consultant/Sub Cntr O'mrvjdt /r Address Za9 �W)Ls�v� City � . lfi�krl orpLic # Phone StJ 307 99q3 <br /> GIS Coordinates: X , Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 1ANEW y11ELlJBORING (CPf, GEOPROBE HYDROPUNCH, HAND-AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ® SOIL BORING# 5.13 -( S , 16 , 171 r g' t51 ZU Z.l ❑ OVER-BORE DIAMETER <br /> ❑ WELL # ❑ PRESSURE GROUT <br /> ❑ *OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑ HOLLOW STEM DIA, OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA:_ <br /> ❑ EXTRACTION El MR 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 N No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS N9Pf — C45TWIC T <br /> ❑ OTHER: ❑ OTHER: APPROX BORING DEPTH 26 of C• Raj S ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> CANDU GR C ING PROP0.5En (if YES, lists R ations in comment miction) <br /> COMMENTS: [JPc + rtemAeAAk czpnyu+ MA OF n �'LD. L/n (� f <br /> NOTE: OFFSITE BORIN (VIGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> -49-WORKING HOURS-NOTICE-REQUIRED-FORANSPEGTIONS <br /> I hereby certify that I have prepa tk�s ia application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Regulation nd I. a . plicable C h rnLaws. � yJ1 � O <br /> Slgned Title/Company `-f/4t "f'Y ��'�q ��C:c `oCYY1l�t <br /> Pdnt Name `�' W X Date J 3 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ( 16 1 a mento CLU <br /> WORK PLAN DATED: 3 'L6 10 <br /> APPLICATION ACCEPTED BY ci DATE ISSUED q 1 AREA <br /> GROUT INSPECTION BY Cf IO FINAL INSPECTION BY 14%Y Arjn ,n DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> 35v (o 41 `133 Sob I ( t{ 2yis W I j 1 to SR# Sj6Sj <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 102W9 WELL PERMIT APP <br />