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SAN JOAQUIN COUNTY <br /> EN-olRONMENTAL HEALTH DEPAR�NT <br /> •` •�" SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> . � Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sogov.org/ehd UNIT IV <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 <br /> San Joaquin County Environmental Health Department. <br /> Well Location J IrAty$1W-d , Cross Street ElVi e Vh �3Tt�e� City o t_\Zip �-14 Parcel#rs23-S'638•D I <br /> Property 11 �` y,�� —�- <br /> Owner�iiy_O IfQ�C\1 Address ��5e6 11IANL Xyd City fa q Zip ..J' '�7Lc Phone# CZb19 S31'94(84 <br /> C-57 Contractor �1 f Vrr_,X 1C• Address.J '72_TaC,r tW_51yd- City -i'WIrI,� D Lic#7b5927Phone 9Z5,521,1q9O <br /> ConsultantlSubCnt ft V•fOf1 cPgqddressZ595E-��_VAAtr0_AC.City tl' C Lic# b� Phon�Z,0q)633,0758 <br /> 1 nC., <br /> GIS Coordinates:X Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW VYELLIBORING(CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> go SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <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 <br /> ©VAPOR ❑MUD ROTARY DEPTH OF GROUTS EAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Ye.)No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ElOTHER: [:1OTHER: APPROX.BORING DEPTH Z51 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> rry CONDUCTOR CASING PROPOSED Iif YES,list specifications In comment section) <br /> COMMENTS: [D �C-b f"O I�-t tl l <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I h ve prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all atVible Califo is Laws ff 11 <br /> Signed Title/Company�e5sd � r1 Fl� IDI C� <br /> Print Name 41 Date 9 1 Z 0 08 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:: fS(ob r <br /> WORK PLAN DATED: I Z f f O_Val— <br /> APPLICATION ACCEPTED BY DATE ISSUED 17 0 1_0'&_-AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY=�—��L�rvt..�'uDATE (0 � <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICOND ITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> SR# 5SS.6?i <br /> 03 1 .00 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) WELL PERMIT APP <br />