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== - SAID JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPT. ivlENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029--- <br /> MITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:WWW.siQov orcl/ehd Cdf�IT I\/ <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 /> �( Assessor's <br /> Well Location Zq cv E �'{tv o11 W�`7Cross Street N• (rola t- Ir 4 e /T Ve. City 5�'or,/c4-oin Zip Parcel#_ <br /> Property2[-�-ICS�C d O )� <br /> Owner Address Cit - d IP +t CA' Phone � --T� 7`j <br /> C-57 Contractor V Address R0 begk a 1 I? City =d Lie# 7'U",-^ 'Phone '>6?-7(o <br /> Consultant/Sub Cntr 1, r `a 1f-/1-o Address Il l K /V--.- 44, u <br /> City E 5= t tf-, Lie# Phone f 3' '`�& fr 5' <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELU/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# <br /> ❑OVER-BORE DIAMETER <br /> 79 WELL# 1AN4t �n^W Z, tr w� MW Iq ❑ PRESSURE GROUT <br /> [3*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS- <br /> MONITORING QHOLLOW STEM DIA.OF BOREHOLE (0�'❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS S C 1A• c I 0 TYPE OF CASING:❑STEEL-9 PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL (AIP FL' TREMIE TYPE TO BE USED®AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_.GROUT SEAL PUMPED:$3 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS "JeA - ce-t,,- L-e-, <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH -7 0 Ff• OBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED o (11 YES,list spectlications in comment section) <br /> COMMENTS:Wetl /Awl CwSFr..cLEt w�1 °/u �` �C� co"of4f Wel AAtN2 N w3 N161J Lyl'tk <br /> MOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS / <br /> CE 1YORKING 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 California Laws. <br /> Signed �)v-k— IJ o.-J Title/Company <br /> Print Name J I,ey CA.5 q tt e fo 4 0 (Ys, <br /> Date Y <br /> DEPARTMENT USE OILY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 02 / <br /> APPLICATION ACCEPTED aY DATE SUE 1dA?/11'8 AREAJ <br /> GROUT INSPECTION BY (/Z 5 FINAL INSPECTION BY DATE k <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMEN T SICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BYi DATE PERM[T/SERVICEV INVOICE <br /> 21 <br /> 161 SR#>` 5S76(6 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERfAIT ENCROACHMENT DOC <br /> EHD 2M1 11/5/07(WEB) <br /> WELL PERMIT APP <br />