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oP idly SAN JOAQUIN COUNTY Q <br /> 2` ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> i 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> P.. phone: (209) 468-3454 Fax:(209)468-3433 Web:www.s o r /e UNIT IV <br /> 4�/i ba ` <br /> �'; <br /> WELLPERMIT APPLICATIOf�NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O /V <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 /> I_ /� ,/� 1, Assessor's <br /> Well Location � tl? Ro IC.live- Cross Street 6VA r� KG1 city 1 ffl Zip Z�� Parcel# <br /> Property 3 v 2 qal"3s <br /> Owner �e C�.Itkovvi (,us. l�{� Address a� I'�IPIM.Ni fT�__ City i-tt 40 Zip 5f Db Phone# LSI, /L'� <br /> C-57 Contractor W0c/ Address <br /> �J'�I)-tU�l( ill PA C��� city �Dj"A� Zip��Lic#` 9� �/9VPhone,,l <br /> ConsuftanUSub Cntr S ' Address N T �1�Qy 1,`141k l� City (O I1 Li,# Phone NO Nd-Uyw <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 BELGA \ <br /> ❑SOIL BORING# OVER-BORE DIAMETER tD7 ( w <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> . ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: ee �aunt -tVlj { avid � <br /> onee,yNV"c �NL <br /> e vb'Me1, <br /> fPI 4t f I I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,v <br /> el <br /> IAONITORING HOLLOW STEM DIA OF BOREHOLE E]MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: Z <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS�C N L-LO TYPE OF CASING.❑STEEL PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL,.UT, TREMIE TYPE TO BE USED$;fAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:*gYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING EIHAND AUGER GROUT SPECIFICATIONS Q C>t0 1 S rt ld►1 <br /> ❑OTHER. ❑OTHER APPROX.BORING DEPTH `y ZOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _ (if YES.list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hero by certify that I e prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an applicable Calif a s. y�y(j <br /> Signed Title/Company ���? {� �qV I <br /> Print Name _ Date V _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 76 <br /> WORK PLAN DATED: v <br /> APPLICATION ACCEPTED BY DATE ISSUED 7 old AR A <br /> GROUT INSPECTION BY FINA T <br /> DESTRUCTION INSPECTION BY Si// / <br /> V_ 6d. <br /> A <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> on <br /> So. o, 3/ sDlat) <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-07 70/28/09 ��� COPY <br /> WELL PERMIT APP <br />