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SAN JOAQUIN COUNTY <br /> : ? ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> Q: <br /> "t € 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ' - Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> °C/l=o RN <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. Assessorr YJ <br /> ff // ��g 5 I'��-e W <br /> Well Locatnnn VAI�GO--�— Cross Street r /�Q• Ciry Zip 5, ,,.. ' Parcel# p p q <br /> Properly [[�� �� TI-- /1 f� s±� / r,•�'�v-PPhone#� / �/ 1Z! <br /> Owner_.�F��`'y��_ Address �'J .Co•�I$Io{�„1��T-citY� -�l� ZIP - �S733o73 <br /> C-57 contractor (A/I�i�•X Or-a. ?-Address 95$D�oyh•�y Rd- 91�13_P� City <br /> ��Or�''-'/ Zip pS.aa6,..eg,.g,�,LiLic#�.332� Phone <br /> Consultant/Sub Cntr f:60 GFUPP Address-�70ErtfcVVaWDa/S'j0l' City Sac�am� Lic#Phone r//6&79ZO00 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) CI DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> =WELL# ❑PRESSURE GROUT <br /> ❑-OTHER�v L,p Ihs-l2t-/Gr'Q oa`r -l-tz la./v:Ohcc-pt�F p�GROUT <br /> GS"PE�CIFICATIOoNS <br /> COMMENTS' 41i C-I Z) IV b-e— 1/'l S GL o,,;- ✓Q//G D w� <br /> ed /4�nW o 2�17�u,rQi <br /> pWJ � <br /> l �s3�c <br /> TYPE OF WELL INF4LLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �40NITORING OW STEM DIA.OF BOREHOLE /❑MULTIPLE CASINGSWIULTI-LEVEL <br /> WELL CASING DIA:_ <br /> [I EXTRACTION ❑AIR HAMMERIDRIVEN CASINGTHICKNESS '/'TYPE OF CASING:[ISTEELXJ PVC ❑ OTHER <br /> ❑VAPOR XMUD ROTARY DEPTH OF GROUT SEALW, /0, 24OrREMIE TYPE TO BE USED[3AUGERS[IHOSE <br /> ❑AIR SPARGE/OZONE El PUSH POINT(GP OR CPT)_GROUT SEAL PUMPEOYYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATION//S\\ / � / 2 / <br /> y <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH fl0, r`o, 2`�0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CON CT ASINGP OPOS I, YES,IiSlapedfic tonsmmmmenlsectionl <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQU E ACCESS AGREEMENT OR ENCROACHMEN ERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> Ihereby certify that I have prepare this application and tthatthe work will be done 1 accord�ith San/J000aagqui-nr County) Ordinances,Rules and <br /> Regulations,ar}dtap licable C ifo nia Lawsl.�`v!�_ 1. lJriv r l� <br /> Signed C Imo[ I�Title/Company p- <br /> Print Name (/Ln 11 WI�IQ�" ` Date ? DO <br /> ryry.. <br /> DEPARTMENT USE ONLY <br /> q,o <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 11.�1� Ab /'�- <br /> WORK PLAN DATED: RA-) l� a <br /> APPLICATION ACCEPTED BY DATE IS LIED AREA �• _ 6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 7 I O <br /> DESTRUCTION INSPECTION BY _ DATE <br /> COMMENTS/CONDITIONS: ✓�✓• > Da CRP <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> Cpl - fit- /yl S9 49- o SR#005'sW <br /> C-57 VVC -WAIVER C57 LEITER OF AUTHORIZATION TO SIGN P MIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> ER02941 1115107 <br />