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SAN JOAQUIN COUNTY <br /> ` - ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> "•Y@ephone:(209)468-3449 Fax:(209)468-3433 Web:www.s'gov.org/ehd MITIGATION <br /> 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 andlor 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, i <br /> f,t. ^rh'' a - Y -� r•r. 1 — Assessors V✓e Inc <br /> Well Location f nut , /a;=-rFi;; T <br /> Cross Street I. ;`r S City l.. Zip t Parcel# .rr, -tom" <br /> 7 <br /> OwnePropert ''r` 1 ,;1Address Gr `, <br /> City _ Zip Phone# <br /> ' C-57 Contractor r� -� ii �s '` i Address t 1�I r° E, 1,� =r' City �'� "i i t Lic#� '�� u Phone %—GJ 4 it_f <br /> ConsultantJSub Cntr ;F t Address /;' ) '` - Cit C I"cr.� <br /> y F-; - Lic# Phone <br /> GIS Coordinates:X Y Township Range Section <br /> WQRK TO BE PERFORMED: <br /> ©NEW •ELLlBORING(CPT OPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [A SOIL BORING# �- ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> -A— <br /> C]MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE • rF ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:f'/(' <br /> ' ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS /} TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER j"j"j' <br /> [I VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL�Ji !1 TREMIE TYPE TO BE USED AUGERS E5 HOSE <br /> ❑AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT)'- GROUT SEAL PUMPED:❑Yes Z No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS <br /> f <br /> OTHER: ?�' �3 ^ ❑OTHER: APPROX.BORING DEPTHS l <br /> ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> ��ss I rr C NDUCTOR CASING PROPO ED (if YES,Ast specifications in comment se�tpn <br /> COMMENTS:�t f t _ft �6 <?�y) i c/1�� �) I tCrl / Gp27 b 1 � i/� 1�3r�5 �a ll t.�f !! � rc '� -C) <br /> ' h'i6r�' jrelf:/VJ <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 applica Ie California Laws, <br /> f r- �. �. <br /> Signed �., Title/Company t Ci <br /> IN <br /> Print Name C �. 1ii i'r _ Date <br /> Q <br /> DEPARTMENT USE ONLY D <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �`��f "� V � -Cl� Int ORt <br /> ' WORK PLAN DATED: C�f,e C.v6tc L� <br /> APPLICATION ACCEPTED BY DATE ISSUED f f ZC b F AREA1747 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY �j DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> d'9 al - 8 7- At- 1112/ Ok, S R# ,?s <br /> C-57 WC -WAIVER C171 OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115/07(WEB) WELL PERMIT APP <br />