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SAN JOAQUIN COUNTY RONMENTAL HEALTH DEPARls..tNT SITE D #". w �� East Main Street, Stockton, CA 95202-3029 MITIGATION a Telephone: (209) 468-3449 Fax:(209)468-3433 Web:www.s ov.or /ehd UNIT IV NOV 0 52,009 WELL PERMIT APPLICATION ENVIN KlNT HEALTH FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERApplication 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 Joaquin County Development Title,chapter 9-1115.3 and theStandardsof San Joaquin County Environmental Health Department. Assessor's Well Location 040 W-A'G r w•}�.�� .Cross Street He�n�,y Q�raw o,. City Zip 963-1'1 Parcel#�3$-1 10-01 Property Owner--7- ElavcMi Address -111 City Dallas Zip '75ZZ1 Phone# C-57 Contractor Clregq ��:ll.�g Address 950 Astwe 9LA- City Mor�irtc� Lic# Phone 0 Z5) $� 313-580 --s� —� Consultant/Sub Cntr So k« Address�n►� Icjr`a�o�e R TSy��a1QQ- City t?0,.,� nrc�c+w Lic#f tab Phone Alto (ot- 00 GIS Coordinates:X Y Township Zroo}tn Range S Section WORK TO BE PERFORMED: ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) Q DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ��j]OVER-BORE DIAMETER ❑WELL# RPRESSURE GROUT mw-i YY1 -� S-1 ❑*OTHER GROUT SPECIFICATIONS COMMENTS: Rt gvg- TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ©BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list spec cations in comment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and all applicable California Laws. Signed Title/Company G Print Name Date 1 1 Z Zc cq DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: WORK PLAN DATED: APPLICATION ACCEPTED BY V DATE ISSUED ! z O AREA GROUT INSPECTION BY FINAL INSPECTION BY C DATE DESTRUCTION INSPECTION BY DATE COMM ENTSICONDITI0NS: ACCOUNTING ONLY: AID# FAC# 1PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE 3-5-02 -+l 60.vo 2-z1'162-�r 0 I+/z:4o9 SR# 59(N C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EFID 29-OS 1115!07(WEB) WELL PERMIT APP