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SAN JOAQUIN COUNTY - <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ._ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.sidov,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 /> Assessor's <br /> Well Location Ia$ E_ Lod: k4k Cross Street S�sc� �o�n City Lo c�: Zip q5 o1�G Parcel# 6`13"p(r R <br /> Property t <br /> Owner f &y 615n,, lv.rcle� Address Liao, S; ..khe% Z Ck City 1AlcaocL6AA5t_ Zip Q520 Phone#Z01-3(�'a�71(�, <br /> -j CS'}- oS`1 <br /> C-57 Contractor Address 52g1Z ?..,�c® gfi/et City Pa..he ca Lic# honect7 S-S2)i- 14 10 <br /> DWS c <br /> Consultant/Sub Cntr ., Address)�S S LbS C6S Q�City ,_ L Lic# Phone�0$'35,C,>-(1;�`� <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PE ED: <br /> 7rNEW WELL/ ORI (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING#+4L- 1 -!Ii, 1'(L-S I�U ST- 1 ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: H L. I I :Lo <br /> t I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE ?- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ` <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS NA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER IoVf1' N <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS El HOSE Vi <br /> ❑AIR SPARGE/OZONE A PUSH POINT(GP OR CPT GROUT SEAL PUMPED:❑Yes AJ No (NOTE:a,_ -UM FREE-FALL DEPTH IS 30') <br /> -VISOIL BORING El HAND AUGER GROUT SPECIFICATIONS C_e Yn a,`"(' b&'4l nrf <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ,-e Zt% [I BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSE- (if YES,fist specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I h e�prepar d this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a•pliCabl atifbrn iai Laws. <br /> Signed Title/Company AAAtU A Gt N G ��l G►�14C.- �,STi4,l�Z'� <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 12 S� ip /� /T u�— <br /> WORK PLAN DATED: c, q <br /> APPLICATION ACCEPTED BY DATE ISSUED / r 7 I AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE p <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-,0 [ `$ 1s S R# _5�gG D <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />