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Utl/lb/2170111 il:U4 'j1b6b1U4JU SEUUK HAUS UL/U4 <br /> 40 • <br /> SAN JOAQUIN COUNTY <br /> ` ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 96202-3029 MITIGATION <br /> P relephona:(209)466-3449 Fax:(209)468-3433 Web;www•s�19P DY�9Lehd UNIT IV <br /> r WELL PERMIT APPLICATION <br /> NQN-Rr=FUNDA6LF PERMrf EXPIRES 1 YEAR FROM DATE ISS__lL <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 Oeveioprnent Title,chapter 9-11115.3 and the Standards of San Joaquin County Environmental Health[)apartment. Assessor's <br /> Sao3 kI r l66oe7L CityT�_Zip 6zoA Parcel# J5/5=G3-o9 <br /> Wall Location &t AVS Or�ross Sheet a..,.,�8yrt! <br /> PropaKyod0 <br /> Ownar�Piu20 QFTRoLEC4n•1 Address 7-6rj /-[gPhone o <br /> G'RCity$ aij&d �2 PhdneR7lA\/ /�4 <br /> C•57 Contractor CgSCy�fJG.DYLL6— Address ?L5Z OIv._{6 �� <br /> ConaultarmSub CntrSTAn/1'a=r' Address 3x:221 A/4 a22a R.v City&Aja-Cd2& <br /> GIS coordinates:X 37 9'37 QCs ,Y -2!& 2� 9 TownshipRangeRange Section <br /> WORK TO DE PERFORMED: DESTRUCTION(CHOOSE <br /> NEW WELUBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTNER•) I ❑�'OVER BORE DI METER TYPE BELOW) <br /> ❑SOIL BORIN # ❑PRESSURE GROUT <br /> WELL I GROUT SPECIFICATIONS <br /> "OTHER <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEGIFLTIONS ,j <br /> AMONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Il O MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:-2 � <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESSSr 14?2O TYPE OF CASING:11 STEEL 14 PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL V19/I.)(J TREMIE TYPE TO BE USED O AUGERS 21 HOSE <br /> ❑AIR SPARGFJOZONE ❑PUSH POINT(GP OR CPn_.GROUT SEAL PUMPED:❑Yes [J No (NOTE:MAXIMUM FREE-FALL DEPTH 19 301) C� <br /> ❑SOIL BORING ❑PIANO AUGER GROUT SPECIFICATIONS ` <br /> Q OTHER. OTHER: .�m�CAC APPROX.BORING DEPTH —,.,}` , BOLTED TRAPFBOX OR []STOVEPIPE <br /> CONDH TDR CA <br /> IN PROPOSED _- PYE9,IIR yeEMeetlmIXl?In mmmanl aeon) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby tartly that I neva prepared this application and that this work will be done I accordance with San Joaquin County Ordinances,Ruins and <br /> Regulations•and all applicable Callfornla Law. : _ <br /> Signed 7 Title/Company �fr4hl <br /> y7•Y?�1­ -Sy Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: Y` - p#/ D i ,I <br /> WORK PLAN DATED: c,00 <br /> APPLICATION ACCEPTED BY OAT, c <br /> II DATE I SUECXJ �'�J—�L--' <br /> GROUT INSPECTION 8Y Za <br /> FINAL INSPECTION BY / ,.���,�l �� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDRION3: <br /> S `tc ., r c� <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK* REOV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR#b05`Q <br /> 057 ' WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHe 2941 117507(WEB) <br />