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or u'n•. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Mair)Street, Stockton, CA 85202-3029 <br /> } <br /> aep <br /> MITIGATIONU +� hone.{209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> 4;� PERMIT APPLICATION <br /> „ _ LUIJ WELL <br /> I+'"=a`-AJH NON-REFUNDABLE PERMIT EXPIRES_t YF,6R FRQM DATE ISSUED <br /> Appli �{ t�7pE��10.J�Iea►Ioaquin County for a permit to construct and/or Install the work described. This application is made In compliance with'San { <br /> Jvagvl ounty development Title,chapter 9-1115.3 and the Standards o!San Joaquin County Environmental Health Department <br /> Assessor's <br /> Wvll Location 77,E 5U/0 Cross street W-LA ZEE F- R�-D- __city TFAC Zip Portal# ala- ag <br /> Property <br /> Owner 6 I}Ir1< ila DEM C. Address 6twl gollil I+' Pc1 <br /> A. city S'ArJ_R K6d -Zip 83 Phone*. <br /> lL r <br /> C-sr Contractor [aNR,II g Address 3307 t I►r+o{ 3k5b0- citySR4�10WV -Zip,�T$?E Lica Phonee7L,76�{ <br /> ConcultonUSubCntr C 'l Addreszjgg(jA� City gLo±� " LiC;r Phone 16 kfrtf2 <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑HEMI WELL/sOM G(CPT,GEOPROBE,HYOROPUNCH,HAND AUGER,OTHER-) �DESTRUCTION UCTI ON/CCHOORE TYPE 13ELOVO <br /> []SOIL BORING# <br /> ❑WELL# XPRESSURE GROUT�. <br /> ❑'OTHER GROUT SPECIFICATIONS b I r <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE QQNSTRUCTION SeEgIEIGATIONSU <br /> MONITORING XHOLLOWSTEM DIA OF BOREHOLE !/ CI MULTIPW CASINGS❑MULTI-LEVEL WELL CASING DIA: Z <br /> C3 EXTRACTION ❑AIR HAMMERMRIVEN CASING THICKNESS� 7 ..'TYPE OF CASING:❑STEEL le PVC ❑ OTHER <br /> ❑VAPOR O MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED CJ AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE p PUSH POINT(GP OR CPT) . GROUT SEAL PUMPED'Q Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH 15 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS �7 <br /> ❑OTHER: ❑OTHER: APPROX.13ORM DEPTH_ `O' __ KBOLTEO TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Of M flat■peace"m In rommmd seemn) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS . <br /> I <br /> I horoby cartlfy that 1 have prepared this application and that the workwill be done I accordance with San Joaquin County Ordinances,Rules and <br /> Rvgulattonc,an 11 appTlr la Calllo aws. <br /> Tille/CompanyGlC1Ak <br /> Signed <br /> Print Name Date <br /> I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: v, `r <br /> WORK PLAIN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED e7� AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY b i)ATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIO NS: <br /> ACCOUNTING ONLY: AID# FACIV <br /> PE CODES FEE INFO AMT REMITTED ' CHECKS RECV'.D BY DATE PERMiTISERVICE# INVOICE <br /> Lit, I SR#,bot <br /> j C-57 WC WAIVER C57 LETTER OF AUTHORIZATION To SIGN PER IT ENCROACHMENT DOC <br /> ti WELL PERMIT APP <br /> EHD 29-01 10120109 <br />