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_bra I <br /> SAN JOA <br /> �o..._.-�•.•.....eo - � QUIN COUNTY <br /> EIRONMENTAL HEALTH DEPAR"TENT SITE <br /> F. 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.SI OV.oralehd T <br /> WELL PERMIT APPLICATION SFp_2 6 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ZQ08 <br /> FN�ga <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application i��l�atp an <br /> Joaquin County Development Titfe,chapter 9-1115.3 and the Standards of San Joaquin County`Environmental Health Department, ISERyfC IIrl <br /> Well Location 0 I�QC BSvd • Cross Street atV Cn�5�CA City I1 Ol Zip �7� Parcel#Ass �sz�U3g"bl <br /> Property/� �1"_' r �' <br /> Owner Ci�`I (!� 1�ae�,;, Address ,.1Q� t�►V�, City IYQ Zip 9537 Phone# <br /> C-57 Contractor i l IA K,Address &5 N 1 inlaM hf city Lie#W�35 bhone 4p��S `B7�L <br /> Consultant/Sub Cntr C1 �E�fgllll`� }ddress IZ RS �CQ��n. c.City Fol Lie#65« Phone Z� []J3 b��U <br /> ICCs f� --.___�r_..�..�.... <br /> GIS Coordinates:X Y Township Range Section <br /> AW RK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑OVER-BORE DIAMETER <br /> 4MSING� <br /> 7C ❑PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS:b11 3b )i oytpS <br /> Ca11r&Samples 4 cpnvrx� tri s qS i rico 2Ww)AUXX41�11- q3oh4wi N 1N:'.kK <br /> 104 owe, 2l' LI'� l'rrid i n b t1 1)r 1 D h s SCO CC d� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGiOLLOW STEM DIA.OF BOREHOLE V-S Q MULTIPLE CASINGS ElMULTI-LEVELWELL.CASING DIA: <br /> El EXTRACTION [I AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:El STEEL PVC © OTHER <br /> ©VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL +++���rrr TREMIE TYPE TO BE USED)(AUGERS[I HOSE <br /> [I AIR SPARGE/OZONE [I PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:Elp�YeS No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> '>&IL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ZS I BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 CONDUCTOR CASING PROPOSED (i YES,list specifications in comment section) <br /> COMMENTS: n L VULITCx ty)UN406nA LOCIIS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS f) <br /> I hereby certify that I havk prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap i a le Californ' Laws ,�ii {y _I� <br /> Signed TitlelCompanyTl•Gj1C.l V1 YI �1 P VU.,lr1%Vlcc��� <br /> Print Name 31 /]ate z pdS <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I M�! JS <br /> WORK PLAN DATED: 12- to 0 <br /> APPLICATION ACCEPTED BY Crites DATE ISSUED -SU O AREA <br /> GROUT INSPECTION BY �'l/yKC1.�T `` i. �"4�� FINAL INSPECTION BY f DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> LPE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 5-v I $t eq.C'* <br /> `I fT 9 3alog SR# SSS4 Z <br /> O (S,o <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 28-01 11/%7(WEB) WELL PERMIT APP <br />