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Pa" SAN JOAQUIN COUNTY <br /> 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.s*gov.org/ehd UNIT IV <br /> %FOR <br /> WELL PERMIT APPLICATION STP—,pWA <br /> 1J <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,cha ter 9-11113 and the Standards of San Joaquin County Environmental Health Department. -2-3s-- llsz-Z3 <br /> n�. _ Imo p �/ Assessors 23S'lSD-o2 <br /> Well Location Si ' (I CCro Street L�/t/�I�/L( �[}/t Cit Q_l /t/�Zi �J 7 W Parcel# 23� IST-02- <br /> Property nn 0 <br /> Owner Address�K-� Address �/ fb City D I'btaltp. NEZip Phone# no�p <br /> C-57 Contractor � D12c I I( Address L.1 O .�rlwU�f•/i 1CAV(' � City Lic#/�tZe Phone ,53 0' taV1-31/9 <br /> Consultant/Sub Cntr 4ddress Z�0 Plt �UYSI_lL sClity �r�d I X A Lic#lK��'F+�Phone510-(0(03 �1 3 <br /> GIS Coordinates:X 12-I .42-(41 Y ?i� �3 Township L .�c�1/�'t'� Range 5 E�;I.sfi Section 2-9 <br /> WORK TO BE PERFORMED: / 2 <br /> El NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 3 DESTI CTION(CHOOSE <br /> Y 5VL W) tb� 7[it�IP.1�S' <br /> El SOIL BORING# <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> � ) �� yO✓ V` <br /> COMMENTS:TO JJWfffVO-4 �f/ 6- <br /> � <br /> {eVtl�Qil�i . <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS .z <br /> n <br /> E]MONITORING [I HOLLOW STEM DIA.OF BOREHOLE El MULTIPLE CASINGS 9 MU LTI-LEVEL WELL CASING DIA: <br /> /�❑EXTRACTION El AIR HAMMER/DRIVEN CASING THICKNESS V•� TYPE OF CASING:❑STEEL [I PVC OTHER&AItant <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL /D f TREMIE TYPE TO BE USED❑AUGERS JXHOSE r <br /> ❑AIR SPARGE/OZONE `❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED.[I Yes O No (NOTE::MAXIMUM FREE-FALL <br /> �DEPTH II'S,30') <br /> [I SOIL BORING 4LJWAND AUGER GROUT SPECIFICATIONS P1 1�1 �/-J-+-- <br /> C]OTHER: <br /> OTHER: ❑OTHER: APPROX.BORING DEPTH ��• ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE f <br /> CONDUCTOR CASING PROPOSED (H 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 application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and al applicable California Laws. 0 / 1 �' <br /> Signed A /� rr ,A�A y� /� TitlelCompany 1_��G� (Ll7(��j7FG C%�� R"u <br /> Print Name <br /> / ��/DEPARTMENT USE ONLY Q d <br /> SITE MAP IN UNIT IV FILE,ADDRESS: [ W• Ilk r4 y <br /> JI <br /> WORK PLAN DATED: Z �Q <br /> APPLICATION ACCEPTED BY DATE E"W67 f <br /> a a ...� <br /> GROUT INSPECTION BY FINAL INSPECTION BY !DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> zRpY foD. D2,g1.6b $A09 SR#058138 <br /> C-57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT �f� Ef�l A� <br /> EHD 29-01 11/5107(WEB) �fM�"'m <br />