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ora" SAN JOAQUIN COUNTY <br /> {H . I ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> .' 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.segov.org/ehd <br /> <rFaR% UNIT IV <br /> WELL PERMIT APPLICATION �o <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED L,'��. Wj <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,r�hapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Z3S- 11! V—Z S <br /> Ih }� �,p Assessor's <br /> Well Location Cross Street ►VAic Alf• City Zip �� �Z Parcel# Z�JS— ►50�dL 9 <br /> Property C 32 5 GVi C (M�r Mit p S3 hone# 2oq"83 I "Io 7 5 2— <br /> Owner Address / Clt (� Zi !� /-��p <br /> C-57 Contractor -RAI yy,,,�'�Ax�ddress�nZ a YG �iity U Lic# /biw�/fi7 Phone 5x,30 <br /> Consultant/Sub Cntr �Lilv'i4adressVD Sl• City a Lic#(01�v Phone /10_19(P•3_'NP3 <br /> GIS Coordinates:X' 17,1 • T Y �• � Township 1A_— S� Range Section ZS <br /> /-. <br /> WORK TO BE PERFORMED: eK �""`' '�• <br /> ❑NEW SOIL BORT G# PT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') VER-BOREODIAMETER N(CHOOSETMPW EM D(1 �Ut <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: V SV- Vfkjeeiay <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE IX r ❑MULTIPLE CASINGS;v1ULTl-LEVEL WELL CASING DIAA,r. �f,�, <br /> El EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS�TYPE OF CASING:❑STEEL El PVC ;91 OTHER e4l!I ww <br /> 1 ' I <br /> VAPOR El MUD ROTARY DEPTH OF GROUT SEAL /0 TREMIE TYPE TO BE USED❑AUGERS>PHOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING JKHAND AUGER GROUT SPECIFICATIONS <br /> [I OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 /> I hereby certify that I have prepared this a Ii tion and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and II applicable Califor a S. //1�,,, ySigned l/L--' nTitle/Company Pkvp�a Loon ��/< <br /> Print Na <br /> M/ (j1V Date V <br /> D/E�P�ARTMENT USE ONLY �O��e <br /> SITE MAP IN UNIT IV FILE,ADDRESS: C( w ` �� 5y' ! .�~' <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISS D LG X09 AREA <br /> ImGROUT INSPECTION BY FINAL INSPECTION B � , _ D DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# 71� FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 17002- 2 515 $-L SR# 9 /S <br /> 6757 V WC Vr -WAIVER C57 LETT R OF AUTHORIZATION TO SIGN T EAD)�­ POERT <br /> EHD 29-01 11/5107(WEB) <br />