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Lj`c 200$ ` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> VIRONME'iT 14EALTSITE <br /> 400 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> PER (209)468-3449 Fax:(209)468-3433 Web:wvvw.swqov.org/ehd UNIT IV <br /> q<%FpRt? <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 /> Well Location LyZ S.�r S 0- Cross Street &1,r arn`q S�rc4 Ci Assessor's <br /> City $-1�ck�o.� Zip 01 Parcel# 13`i'ZSa-OS- <br /> Property <br /> Owner A'E Cl- OW X-e CCn}lr Address L 0 0\ Un,#^ ii. 0300 Cit SAA an FEsc.Zip I tjl1-_1 Phone# 4 If-sari—gos3 <br /> C-57 Contractor CaS[o.A4 D.:1%tea Address 31132 OMCC C:mlt City rZa-1c„o Cprsh;,,Lic# Phone q16-(03 <br /> $-1161 <br /> ConsultanVSUbCntr A4tN11ZII--xS Address ?S0 r, GIew+ O^VIC City Falsor Lic# Phone 4114- ` 9F-7074) <br /> GIS Coordinates X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,NEW WELL/BORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) F1 DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# Mw't ❑PRESSURE GROUT <br /> 'OTHER _ GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING >rtlOLLOW STEM DIA.OF BOREHOLE p� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2- <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS p,�1Z S TYPE OF CASING:DkSTEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 32 _TREMIE TYPE TO BE USED❑AUGERS❑HOSe re^.�c <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> F-1 SOIL BORING El HAND AUGER GROUT SPECIFICATIONS OCn�o� f'2 Ctn+cn1r /UV�C <br /> ❑OTHER ❑OTHER APPROX.BORING DEPTH ILIO BOLTED TRAFFIC BOX OR [:1 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _ (if YES,list specifications in comment section) <br /> COMMENTS Mw-1� C�'1d�ds�-- Cr'Si�s Ccs G 11�' wCb—!f G ar�e•:�.r. !40 sCrct. lro, I;f-ILfO <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 applicable alifornia Laws. <br /> Signed Title/Company Ce-•e-4.4 t- <br /> Print Name -1 ,,44 1Cn ( Date /ZI <br /> DEPARTMENT USE ONLY JFILE ' "r <br /> SITE MAP IN UNIT IV FILE.ADDRESS _5w"! -t.-_ S•} t. t <br /> WORK PLAN DATED 1017-01c, -6 <br /> APPLICATION ACCEPTED BY DATE ISSUED *, AREA <br /> GROUT INSPECTION BY L(InAn,.r a �_� O� FINAL INSPECTION BY Vii�C L� - DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: T n <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE#7 INVOICE <br /> 95-01 1i$9.00 o3BsS"Z (Ak pS SR# S6 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5107(WEB) <br /> WELL PERMIT APP <br />