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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029- -jLeP MITIGATION <br /> hone: (209) 468-3454 Fax:(209)468-3433 Web:www.5jgoy.orq/ehd <br /> UNIT IV <br /> LU Ij <br /> WELL PERMIT APPLICATION <br /> .7 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <br /> Applic aquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaqu )County'Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Well Location 775]VII BLVD cross stretW-L/t?--cA City Assessors <br /> Property - -Zip _ Parcel# �Ll;( -II70- <br /> Owner—CRt--VF-'t� EM"- Address 60ol City SAN KAR61� Zip ffrI3.. Phone# <br /> C-57 Contractor CON Fl/,VO(r,- OJV Address '3301 0-6AKii-ID AVS31t5kO city YAL"Pt--liD Zip I Lic# I)7)q� Phone-p..-76 <br /> Consultant/Sub Cntr l t Address 1010 114K(&T'9L P/' Rh I pg- city 60P� Lic* Phone b)70-f f 2L <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> [ij NOW WELLIBOMNIG(CPT.GEOPIROBE,HYDROPUNCH,HANG-AUGER,OTHER") DESTRUCTION i"CHOOSE <br /> CHOOSE TYPE BELOW) <br /> El SOIL BORING# E]OVER-BORE DIAMETER <br /> ❑WELL# XPRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS Sit, <br /> Ej EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE <br /> El MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br /> C1 EXTRACTION E3 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:El STEEL 9j PVC C1 OTHER <br /> [I VAPOR E]MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED El AUGERS t3 HOSE <br /> 0 AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:El Yes [I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30'? <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: C1 OTHER: APPROX.BORING DEPTH J�r BOLTED TRAFFIC BOX OR EISTOVE PIPE <br /> CONDUCTOR CASING PROPOSED (it YES,fist 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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation Ic Califorpj�,Laws. <br /> TitlelCompany (' t <br /> r� "rr- Z6FA <br /> Signed _ M;;;� I <br /> Print Name Date OqUl 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 'Al' I-A"-" L'-�A",�/ ' <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED By <br /> DATE ISSUED 6/0 AREA <br /> GROUT INSPECTION BY FINAL INSP �70 By DATE <br /> DESTRUCTION INSPECTION BY DATE_7/ !e'101 0 <br /> I <br /> COMMENTStCONDITIONS: dAzo>"Is� Ql L 0. <br /> ACCOUNTING ONLY: AID# -FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVD BY DATE PERMITISERVICE# INVOICE <br /> SD-z- 60- 60- 3a61ff==� 6 LVI 0 SR# 60363 <br /> C-57 WC -:!-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28109 WELL PERMIT APP <br /> LI <br /> ��3 3711 375 <br />