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SAN JOAQUIN COUNTY �..+ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Gov Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.s' oV.or /ehd <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES i 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 /> Well Location ',t��S �� ;ti�K_. Cross Street w=s� L, ke..,a 53�r� Assessors <br /> Property City 'S6:�h�n Zip �1Zc7� Parcel#_ 1?s i-coo -�1 <br /> Owner e' i4h Address X`) r,. 1ao� S]�! <br /> -�-.. City�•- ,._-ka1;;4 Zip 7-?4k7 Phane# <br /> C-57Contractor <br /> C. r .c 7) y Pddress ?ll'i'� 3�t�c ( 4�1�- a,City I�'0"a L.r. ;Lic# 71-Wla <br /> Phone <br /> ConsultandSub Cntr r <br /> 5 Address ��� Cit r�6- <br /> Y Lic# Phone tit,- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION{CHOOSE TYPE BELOW) <br /> SOIL BOOZING#_. �a� ❑OVER-BORE DIAMETER <br /> [3 WELL# PRESSURE GROUT <br /> ,OTHER <.1n 1ln GROUT SPECIFICATIONS <br /> COMMENTS: t/ <br /> \ <br /> �irP� ` 113 s�;>? --�(-4 ► S�'�- Aft ;� •-e:�, f' S.�. <br /> -Ad 5 i --3 r 5-3.1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORINGHOLLOW STEM �--�P "'n'fr <br /> E� �]A`w1y DIA_OF BOREHOLE MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DfA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS <br /> TYPE OF CASING:D STEEL ❑PVC ❑ OTHER <br /> KVAPOR ❑MUO 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 S�-No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING HAND AUGER 5Lrw1i0 ' GROUT SPECIFICATIONS _ CEn'1e^t L I - IA <br /> EI OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED <br /> COMMENTS:-` {if YES,list spacifieadorls in comment section) <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,and all applic Ie California Laws. <br /> SignedTitle/Company S"h �S Arc •�.++5 <br /> Print Name & ^t.-r IGrehS+-A Date IZrll><f�� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ���q r 1 S'--74D <br /> WORK PLAN DATED: 8� <br /> APPLICATION ACCEPTED BY DATE ISSUED I AREA—t � <br /> GROUT INSPECTION BY G .� FINAL iNSPECTION BY DATE '116105 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSIC ONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC* <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN P RMT ENCROACHMENT DOC <br /> ENR 29-01 1115107(WEB) <br /> WELL PERMIT APP <br />