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t • U <br /> COPY <br /> SAN .10AQUIN COUNTY ���� <br /> •i <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-302�EB Z 3 2010 <br /> • -- MITIGATION <br /> Cf ��` <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web: <br /> FF: <br /> www IN Ir HEALTH UNIT IV <br /> WELL PERMIT APPLICATION PERMIT/SERVICE <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 /> T � Assessor's <br /> Well Location Cross Street /�ppy &X City Zippo <br /> Parcel#235-/ a73 <br /> Property p,� C <br /> Owner P Address Iyd�.`I a-�%_ D� City O Zi I] - bPhone# .7 y <br /> C-57 Contractor G u rI I Address �50'�1Pli.>'<•�7U AVQ. City M `+ Lic# Phone�3 "�� <br /> ConsultanUSub Cntr, Tom,�WHtd+{rttr Address a101 t)6S+G, -+, City l,CLV—6 J Lic# 01 0 Phone s/O-j�43--"//00 <br /> GIS Coordinates:X 3:7.15q. Y —(?-I•_ y Township � �Cl� Range�_Section 0 <br /> VVPRK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,(-,F(1PRnRF HYDROP NCH,HAN -AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 0 C.Fn-',A,(o,^ - ) ElOVER-BOREDIAMETER <br /> -171 WELL# _ ❑PRESSURE GROUT <br /> ❑'OTHER - ,f' GROUT SPECIFICATIONS <br /> COMMENTS: b[EL�(.01^ 3 0�wftc�l=byn"S L"z 4n 7C+ 6qs <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER i <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE $[PUSH POINT(GP OR GROUT SEAL PUMPED:C]Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30')) <br /> SOIL BORING '`HAND AUGER GROUT SPECIFICATIONS �J Z� PO{ :41,2 yi / Cam-y-^1 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED I (if 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 /> hereby certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d all a plicable California Laws. <br /> SigneTitle/Company <br /> Print Name Date_?Z/9y//O � <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / f�•�p�� O 'C/`( / /V U l> "� ,(p <br /> WORK PLAN DATED: c3 M Amo <br /> APPLICATION ACCEPTED BY ATE,ISSUE -�6 AREA <br /> GROUT INSPECTION BY FINAL INSPECTIO — - - - - DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D B DATE PERMIT/SERVICE# INVOICE <br /> IT 2, 3 /U R# <br /> ZOSSS O� <br /> 04 <br /> C 57 91 WC if -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN P RMT ENCROACHMENT DO <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT PP <br />