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FILE COPY <br /> 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.siaov.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- 115.3 aQd the Standards of San Joaquin County Environmental Health Department. <br /> To a,dAssessors <br /> Well Location vov ' ross Street City i�\(�� ZfIJRS_V,C Parcel# :l C 0(6 <br /> Property <br /> Owner .�Y� -�v�� �. �ddress J k'>1A '9 OG City o�/ Zlp j S 3C Phone# <br /> C-57Contracto"Nin �)W\\ff,'A dress <br /> Co�nsulCkaCn'flS�u�b Cntr�`� t'S ��`� "AH sus S\ \n�S� City P v� Lie# Phone o t rJ`C <br /> - GIS CodrT"d�n'afes:SX���} ` Y Townships y Range I(Z$ Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELUBORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [9SOIL BORING# ❑OVER-BORE DIAMETER <br /> Q WELL# L ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: -M.:^w <br /> TYPE OF WELL, INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /� <br /> MONITORING'" �HOLLOW STEM DIA.OF BOREHOLE-%-- MULTIPLE-CASINGS❑MULTI-LEVEL WELL CASING DIA d/aK4 <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SC1nQ��JYPE OF CASING:❑STEEL 0 VC ❑ OTHER G �a Ly>t- <br /> �� 0-�f r <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL /^7/ ' TREMIE TYPE TO BE USED GAUGERS L9'HOSE WG// <br /> ❑AIR SPARGE/OZONE 'I!3,1PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 54 SOIL BORING.3 ❑HAND AUGER GROUT SPECIFICATIONS Y'v�2 dry"t neM� <br /> ❑OTHER: <br /> POTHER: SU WL APPROX.BORING DEPTHS ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASINO PROPOSED (It YES,list specifications In comment section) <br /> COMMENTS: <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, ppl cable California Laws. ( \ <br /> Signed Title/Company <br /> Print Name N N II/�� Zp I <br /> ►"�R- Date <br /> /� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -! 3 zr e <br /> WORK PLAN DATED: N D d onyb - 5- fT0 9 <br /> APPLICATION ACCEPTED BY <br /> / U i C-+f)Y-i !J YI L' ( ", Y DATE ISSUED 0 AREA 145'9 <br /> GROUT INSPECTION BYy 1`^ nfi MA14AY'421A!�7 FINAL INSPECTION BY Ill j'C Or!d n1 d6Q t f7ZPs, DATE $-6-10 <br /> DESTRUCTION INSPECTION BY �t DATE J <br /> COMMENTS/CONDITIONS: Z71�fQ 1 Qi l UYl nT "r mb�► I D)c I�is &n 4 Gt van e ErY1_e <br /> AJ- <br /> el <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 290 l ar 89.6_4 89 ad 26, 77 -I4, i0 SR#fi00s9482 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />