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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> a: <br /> „a ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ', 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> lar ` Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.slgov.orq/ehd UNIT IV <br /> p�)•1 F O R�`r <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 /> " _ Assessor's 2 L -OZ 0 <br /> � { <br /> Well Location �1�� r�,.��� ross Street �f Q City Parcel# <br /> Property ,� <br /> Owner Address11 OS <br /> Zip !A Phone# :> V '2.\ 3 <br /> C-57 Contractor4;Sfa .,\k+ . dtcls'Q,,5ess c# (Phone k�(N GGq <br /> �Qonsul anUSub 'F, City Lic# Phone �� ZO•:�� <br /> L r. <br /> GIS Coordinates:X X _. ,Y ,Township �.Z� Range 1�:� Section <br /> WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# )�- E3OVER-BOREDIAMETER <br /> 614ELL# PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: ti <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> &,'MONITORING 5 HOLLOW STEM �4) DIA.OF BOREHOLE 3,=-� ❑MULTIpt F CASINGS[IMULTI-LEVELWELL CASING DIAD 0,— 12 <br /> / rr�� ` Dr <br /> $EXTRACTION of ❑AIR HAMMER/DRIVEN CASING THICKNESS SC11\g�l OF CASING:F1 STEEL E•YrVC ❑ OTHER <br /> CCtS; <br /> ElVAPOR -fTMUD ROTARY( �=) �- —DEPTH OF GROUT SEAL 181 TREMIE TYPE TO BE USED 9-�KUGERS OSE <br /> ❑AIR SPARGE/OZONE '®'PUSH POINT(GP OR CPT),(�2 GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> IYJ SOIL BORING ❑/HAND AUGER GROUT SPECIFICATIONS Yl�.5.�.� LCl Y,,,`:.•l`� <br /> ❑OTHER: El OTHER: 11)\C•- APPROX.BORING DEPTHBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTO CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: ���,✓\Yi�.. �� ,ter, v���wa" +�+ -Std F� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS W <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,and all a icable California Laws. f� T <br /> Signed Tllle/Company <br /> Print Name R Date W <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 Z (--��n�4 A e— t< <br /> WORK PLAN DATED: ,I <br /> APPLICATION ACCEPTED BY V l Gf- ,Y) 1 Y DATE/ISSUED U AREA <br /> GROUT INSPECTION BY i fieri A YrI!'�yYTnC�i FI AL INSPECTION BYY b r:4 SII /l4,4njeDATE L 17- o <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 2- e)cfY4,cj-10Y) r'ye lis an z "�C111 <br /> �F4•�$0 .{ b0rin s • i <br /> ACCOUNTING ONLY: AID It FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Z90 / gip.ego OQ11, O 2 6 77 -tfM 411,110 SR#00S9G 90 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> EHD 2901 1115107(Were) WELL PERMIT APP <br />