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SAN JOAQUIN COUNTY +i <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> a• � <br /> t 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.siaov.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 /> �W�, Assessor's <br /> Well Location 7rYr{0 N.HgS,ryy ti� Cross Street Na ht City S k�., Zip gS11L Parcel# d$)•D'(I>"33 <br /> Property/r � <br /> Owner C'0- Canna vrkd Address y443 C1+/-/e kit U. <br /> / City �r, Zip Phone# <br /> C-57Contractor WIL11,y Address SSOPWO R^rµ II�� 1� I City 2,U V4, Lie# j Phone )67)74.430) <br /> Consultant/Sub Cntr 5�4,k5 LAv. Address )330 Cav,,1w„ I'ww�l � CutMtr`ex -vllrlc <br /> W. CI gj,c�W Phone $)D'E+"7G-4oag <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORI^IG# ❑OVER-BORE DIAMETER <br /> WELL`OTHER ElPRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA,OF BOREHOLE _Q_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: n <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 9C� 40 If TYPE OF CASING:❑STEEL A PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 61TREMIE TYPE TO BE USED❑AUGERS,}HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:C(Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS M4 Gti,4 P <br /> r <br /> [)OTHER: ❑OTHER: APPROX.BORING DEPTH KS 19-BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (, YES,list e <br /> per cations In mmmenl seUion) <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,an all applicable California Laws. / t,�- (L,�( r -i <br /> Signe /I Title/Company &Colli`* 1 nr"Y1 irm III,, <br /> Print Name 4�Iy 6a W tit( Date 9/1I/6v <br /> DEPARTMENT USE ONLY FILE <br /> SITE MAP IN UNIT IV FILE,ADDRESS: b Ica e-J CL S^}o e t et- <br /> {�, <br /> WORK PLAN DATED: aAdA e:u-ti . It r ID <br /> APPLICATION ACCEPTED BY �it.�-inn.�e-ens DATE ISSUED 1012,14, k AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE At- vlsl <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM E N TS/CO N DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 35'0 l -F89-0C (90- I-)VO Fr SR# SSsg3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5m7(Wi WELL PERMIT APP <br />