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�oPgv.!rr. 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 UNIT IV <br /> 9C%FORa` <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 Department. Assessor's <br /> Well Location <br /> y7vl l' A� Cross Street /�',�'� 1,4,4_11�— City 57 O-C-`zip q,9�07 Parcel# 0 <br /> Property -"fC@7c'T [.:'��� Address es 19 q City l 7S Zip S3 Ct phone#• <br /> Owner L83�y,C <br /> 6vpG Px a ATiz++� P <br /> C-57 Contractor ej W�C'�Z�-f1��-5 Address -ISDa GD�/w.r(l R8'TU 73B City Z'1�'MOR� Zip _Lic# �_ hone <br /> Consultart/Sub Cntr STii�em GPM'//dress? QO ^64—WApO RID0 f�'� City-r�//r�+VI`r� DABS Lic#—Phon D Z 0— 2 <br /> 6 y 8�2. Y y Z��j G j Township Z/V Range 6 9 Section 2 <br /> GIS Coordinates:X P 0•Af <br /> (S3 )a7- r <br /> W RK TO BE PERFORMED: DESTRUCTION (CHOOSE TYPE BELOW) <br /> ' NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER OTHER•) ❑OVER-BORE DIAMETER <br /> SOIL BORING# i ❑ PRESSURE GROUT <br /> ❑WELL# GROUT SPECIFICATIONS <br /> ❑*OTHER ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING HOLLOW STEM DIA.OF BOREHOLE 9 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NATYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 9a TREMIE TYPE TO BE USED WAUGERS❑HOSE <br /> `❑ <br /> AIR SPARGE/OZONE F-1PUSHPOINT(GP OR CPT)_ GROUT SEAL PUMPED, as ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> IMSOIL BORING El HAND AUGER GROUT SPECIFICATIONS� � � G E'00T <br /> ///❑lll OTHER: ❑OTHER: APPROX.BORING DEPTH __nom_-- El BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED A�A 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 1 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 California Laws. �6 <br /> f <br /> Title/Company <br /> Signed ���z- 1i0.✓>(/GT�•!�L — F.f/�OR lits �v� <br /> Date <br /> Print Name G G� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> r � _ DATE ISSUED _AREA <br /> ( <br /> APPLICATION ACCEPTED BY A f'C^l� <br /> GROUT INSPECTION BY /J�ti <br /> FINAL INSPECTION BY (�� A6 n-^� DATE P <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: E­ a, <br /> FAC# <br /> PE CODES FEE INFO # RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3Sa� 3zo E f� SR# S <br /> C-57 WC -WAIVER C57 ETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 10/28/09 <br />