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SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Mai Street, Stockton, CA 95202-3029 MITIGATION <br /> -, Telephone:(209)46E 'W49 Fax. (209)468-3433 Web:www.s ov.or /ehd KNIT 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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ,� Assessor's <br /> Well Location $ tn[ !c vE Cross Street ,4A-L-NyT S"T City STOLAL1 OY� Zip .2�:jc Parcel# 13-10 2-C>I I <br /> Propertyr� <br /> Owner_t�Ff E� k�SS>r L CAddress �x 5�7 <br /> City Zip Zip^} phone# <br /> C-57 Contractor% D , {►cAddress663L Orti c CityEfwUto„ Lie# 1112 Phon <br /> Consultant/SubCntr Z15Address tLGNJ� �CIia•S`Qti.J <br /> !+ � <br /> Imo, City w� Lic# Phone. /I{a •9 s� ZU-7Cj <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [.DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ®-OVER-SORE OIAMETER. <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS; e9-0 9.t lb "' �2tl3bS ktrit> GRbumP-z-Ca 3'C cj.tLC'—YkCe <br /> ttiS t►.tin _ ..`�rc►�ht1C >°ti r?1 hlfet �.� .� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �g'MONITORING �IOLLOW STEM DIA.OF BOREHOLE I �� <br /> {� � ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DfA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL-11, TREMIE TYPE TO BE USED❑AUGERS ZHOSE(_t'VG) <br /> ❑AIR SPARGE10ZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:DkYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH �Z 1 ❑BOLTED TRAFFIC BOX OR ❑STOVE P;PE <br /> COMMENTS; GONCUCTOR CASING PROPOSED (ir YES,list specifloations in comment Section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 applicable Califor <br /> Signed . ' TitlelCompanyQ s. -r S <br /> Print Name x Lrt* Date., S. <br /> // DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: f <br /> APPLICATION ACCEPTED BY DATE ISSUED 11AW, /!�',L4lkAREA 1'153 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE h7.9—6V <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICO NDITIO NS: ( <br /> �-rC� c e,.�.P-d 6• u� .,oa_,•►�-. -77.1-•-�,c-� <br /> �r3K <br /> ACCOUNTING ONLY; AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3 5c}za �Ca ” �:? �� 10)"A SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHO 29-01 1115107(WE$) WELL PERMIT APP <br />