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. . -( SAN JOAQUIN COUNTY <br /> {: >< :.�� 0 ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> -. > 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> hone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.orglehd UNIT IV <br /> Go\eq <br /> WELL PERMIT APPLICATION <br /> opa SME SME <br /> SpN�NA\?p VN NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby nfo San Joaquin County for a permit to construct andlor 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 /> Assessors <br /> Well Location I`1?t'I 1:. llr.,tt 171 cross Street t'ferlan (gip Qd cityR)T`Zip Parcel8 ZZO <br /> Owner Wb ..,� &Vtt rLx Address rid [tL!, iz-) City Zipgr=Phone* r�'� r1) <br /> C-67 Contractor ,,uu , Address L'73p -[ [a city lf� Zip L7 -- Lic t(rr2ilnrhone30`16C* <br /> ConsultantlSub Cntr L per ( . Address 135 S•R k A* SIe �Ciry Llc��Phoneme�-82?0 _ <br /> GIS Coordinates:X Y Township S Range $ E Section .33 Q <br /> WORK TO BE PERFORMED: <br /> EW WELL113ORING(CPT, OBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> DSOIL BORING>x�_ 1 0 OVER-BORE DIAMETER <br /> WELL tf ❑PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING HOLLOW STEM DIA.OF BOREHOLE <br /> �_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION O AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 5-60 TREMIE TYPE TO BE 11SEO UGERS�HOSE <br /> Q AIR SPARGFJOZONE []PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:KYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING ElHAND AUGER GROUT SPECIFICATIONS As& e� aw4"-t-, <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH •tTCT ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONOUCTOR CASING PROPOSED id YES.Iln speofiretiaru in owynwg smaim) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cartify that 1 have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an all app, California La sr <br /> Signed .'a"��"��- Title/Company +AaD6q; z Lee 4_r1E(ft -_1;-O- - <br /> Print Name Dater. I y Zl1Dg _ <br /> DEPALtRTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _ [�-� 1 TTG.�ti ZD - <br /> WORK PLAN DATED: tti 3 <br /> APPLICATION ACCEPTED BY DATE ISSUED (p S AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS_ <br /> ACCOUNTING ONLY: AID S FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK i RECV•D BY DATE PERMITISERVICE/ INVOICE <br /> -3 $.si--o I� 6&oS SR# 5y't;� l <br /> C757 WC -WAIVER.,/y C57 LETTER <br /> OF AUTHORIZATION TO SIGN PERMIT le- ENCROACHMENT DOC <br /> EM029-01 IIW7 �+` � 'J WELLPERMITAPP <br /> 3so3 <br />