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SAN JOAQUIN COUNTY 'mow( <br /> F � ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> `fog 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s'ciov.org/ehd UNIT IV <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. <br /> Well Location 0515' JAck$o- Ave. Cross Street 3!d SirGG{� Cit Assessor's <br /> y ESGAIWC Zip9532o Parcel* 271-19"Y-00 <br /> Property <br /> Owner Address PO BOA Z 0 to City ES Ca Iw, Zip 9 53 20 Phone# <br /> C-57Contractor J`jFW�r"\`% -Ev'r•Address �0 oX Q,70 City LD d i Lic# 'f2.09'DyPhone 369 9600 <br /> V*", ..d lero l <br /> Consultant/SubCntr D°e,�lT�r;C,c, Address 1-1 1`I M6.^ Sf"ff--- City ES CA I"— Lic# Phone 8178- ?-rte <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION(CHOOSE TYPE ELOW) <br /> ❑SOIL BORING# [�OVER-BORE DIAMETER VV-) kox t VvU J b <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS:We[IS \iWlq A VINI lnta{Q�J w.1�i/I qwe �/YQ�dt <br /> U W—Z <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS //� <br /> (I MONITORING )Ki HOLLOW STEM DIA.OF BOREHOLE 10 If ❑MULTIPLE CASINGS[-]MULTI-LEVEL WELL CASING DIA: /"rI <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N Pt TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 93- FF TREMIE TYPE TO BE USED9 AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:'FYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING C3 HAND AUGER GROUT SPECIFICATIONS /V&M+ Ce✓ NL41 T (rr0 v�— <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Liz F{-, ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 Californ aws. <br /> Signed ,y) Title/Company Sf-AW 6-edle 91 S /(!/a vr%d z end <br /> Print Name Date -Z 3�0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I &Sf, ac SG 4 V—c <br /> WORK PLAN DATED: R Z,/QC rj <br /> APPLICATION ACCEPTED BY l.� ,. . DATE ISSUED OI26 a AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY_ ���. DATE <br /> DESTRUCTION INSPECTION BY ..�„„�, „ DATE_ p�g�pg <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> L010 1 '460,00 01.%27 v V 26 08 SR# b 555'1 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) <br /> WELL PERMIT APP <br />