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,o°``; ) SANS,JqA QI AN COUNTY , �, qA .'E. ) 10��a1: •• <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q:... ,,. SITE <br /> . .. 600 East Main Street,Stockton, CA 95202-3029 MITIGATION <br /> ;P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siamorq/ehd UNIT IV <br /> ORa <br /> WELL PERMIT APPLICATION i <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE COPY <br /> I. <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 101-- �2o`&M/ GE RDCross Street ��/�h`S LAS► City 1\1 Pon) Zip S Parcel# ZG`�nal -04Propety - <br /> Owner—0� : „ S Y Address `S00 I.Lat,:J Ind City N „ �a� Zip 94070 Phone# 6S�'-Sl(, -%IS o <br /> C-57 Contractor e t Address T5 U Howe 6&A r, City �RRrrQrs a Zip °I`fSS 3 Lic# a7:f891"Phone <br /> Consultan ub CntrC 9-13 Address S`9a, 4,1 City LtirJQ /t L-E Lic# _Phone SIu 47v3 <br /> �h Sty 'tZa_ g17o <br /> GIS Coordinates:X Y Township Range Section I <br /> WORK TO BE PERFORMED: <br /> . NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> 13 WELL# PRESSURE r'-Pf)l IT <br /> WOTHER F-le � S?CM GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD vm 3-,6,!of <br /> t ta�� J �Y �� 35 t m 3G11-10 /0 r✓ <br /> COMMENTS: 1/9c �'Y�cL- r t PurNN ce o...t u av S?Pr.. fd � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> CkMONITORING HOLLOW STEM DIA.OF BOREHOLE /0,1 [3MULTIPLE CASINGS[3MULTI-LEVELWELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL 4 <br /> 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 /> ❑SOIL BORING [3 HAND AUGER GROUT SPECIFICATIONS \ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH3S IxBOLTED TRAFFIC-BOX--OR--❑-STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (i YES,list specifications in comment section) <br /> COMMENTS: 4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS f <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS i. <br /> I hereby certify that I havtjprepar;oAkns application and that the work will be done 1 accordance with.San Joaquin County Ordinances,Rules and — <br /> Regulations,and a <br /> all cab lif nia Laws. <br /> Si ned <br /> 9 Title/Company /f&g f1f ":t.'iizCKn <br /> Print Name l ALv I Al to _Date 51 r°%V <br /> CDEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: U 2 1--Z E. �YOnfcf Q G �IX - <br /> WORK PLAN DATED: J V nr— 30 .2 D o q <br /> APPLICATION ACCEPTED B\Y/ 1 C-+b Y- i Ck e�( r+-ri 2 c 1 DATE ISSUED 3'-1 -/0 AREA 14561 <br /> GROUT INSPECTION BY �1 i for l cx ML'Ca -tyie y FINAL INSPECTION BY Vi Vf df i Ot fflh4'V� DATE3-jjI. <br /> DESTRUCTION INSPECTION BY DATEto l <br /> COMMENTS/CONDITIONS: 1 S }<r. }�cl�`i art t � YYl m V3- <br /> �o n �'�-Or' <br /> � _ <br /> I <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 290 89. 60 $Q. 00 /08 ? 3-10-/0 SR# UOS9$83 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28109 WELL PERMIT APP f <br />