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n •" `/ 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.si0ov.ora/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 /> Well Location RLJI y ` Cross Street eke A City S'CI��I��`I^ Zip t� Parcel# �� `f U-3 t{ <br /> ownProper li erF Scan a SIkC) Ci`errk4e 2a, 7il-VL�(I�a <br /> Owner I n V,'v\0 Address n 11 City I� II /+ Zip Phone# <br /> C-57Contractor Wuudvo,.c( �)AIhG Address S(it; ia" 2dav( Cit R1� Vhk Llc#7101'7 -(II,O <br /> � Y t� Phone 7d7-3?U <br /> ConsultantISub Cntr S4+ kt Lh V. Address 3))0 CoyAtrz. Pc,k br, "^City G'MeV+H Fvlk LicitPhone s)0-671-2014 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPEDE�OW) <br /> ❑SOIL BORING# OVER-BORE DIAMETER_JU 4,w, M.I�-1 <br /> ❑WELL sit ❑PRESSURE GROUT <br /> [I-OTHER n �" GROUT SPECIFICATIONS <br /> COMMENTS: Mw-1 4 411 Alkm4r PVL 1 .7 .�ft,�- ct- p, <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 TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> "- SOILBORING [I HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR <br /> ❑STOVE PIPE <br /> COMMENTS: CONWCTOR CASING PROPOSED (if YES,list sperrm <br /> cetions in comment section) <br /> _NOTE: -QFFSITEBQRKG.S_REQUIREACCESS_AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 /> Regulation'#anll placable California Lawsl, Title/Company GeoIO�•54S�+^a 'fAJ �r\ tJihmeI^ 'Nn Date U� <br /> DEPARTMENT USE ONLY ^ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: .(71 b U A) ,1-}c,A-� 5' S l Co� P� n <br /> V <br /> WORK PLAN DATED: 0.49 j Vv Ln '3- <br /> APPLICATION ACCEPTED BY U1,S AA Ag.-„� DATE ISSUED 11113to—sir AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT RECHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 35vL MITTED-41%It3oIK- I SR# 3.5101 <br /> C-57 WC -WAIVER U57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHO29-01 11/5/07(WEB) WELL PERMIT APP <br />