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SAN JOAQUIN COUNTY <br /> - -.ENVIRONMENTAL HEALTH DEPARTMENT <br /> 'g .600 East Main Street, Stockton, SITE <br /> CA 95202-3029 MITIGATION <br /> Telepfione:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.orp/ehd <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> NNy 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 San Joaquin County' En <br /> viron me�ntal Health Department. <br /> GwI/ ` <br /> Assessor's,r-- ;rty - CiWell Location-- ross StreetPro eZi 4 Parcel# - <br /> )— , <br /> Owner C _ <br /> Address' ^` <br /> r r ' l _' City �:r' `' Zi ]. �:P fir'— *j_;4r.� <br /> ' 11 y i i . --�—._— P Mone# _ <br /> C-57 Contractor t^� I rVI(i,it Ac, Addressr.2 I V `;`� 1, r 1 " t i <br /> r i. -(' � 4'J � � ;5.r. City I.rucT>�(e;,,ly Lic#��C�.�i vvhone �s`Jew�'•2,`I.,, <br /> Consultant/Sub Cntr - Address <br /> City Phone <br /> ' ;:. r 4 Lic —,^ <br /> ' GIS Coordinates:X p� # l-%,'Y Township Range 9 Section <br /> WORK TO BE PERFORMED: <br /> A NEW ELL/BORING(CPT;GEOPROBE, YTOPUNCH,HAND-AUGER,OTHER`) <br /> L/jSOIL BORING# b` ''F �� DESTRUCTION(CHOOSE TYPE BELOW) <br /> El WELL# ❑OVER-BORE DIAMETER <br /> [{'OTHER OPRESSGROUTS PEC FI ATIONS <br /> COMMENRE GROUT <br /> TS: <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3,25 kk <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:1�' <br /> ' ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS _ <br /> TYPE OF CASING:0 STEELtV <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SE 7—. ❑PVC ❑ OTHER <br /> ! f <br /> / p AL,, TREMIE TYPE TO 8E USED❑AUGERS HOSE <br /> [3 AIR SPARGE/OZONE ®PUSH POINT(GP OR CPT) 1 GROUT SEAL PUMPED:❑Yes M No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' ELI/ OIL BORING <br /> �,�, `. ❑HAND AUGER GROUT SPECIFICATIONS 7,/cc� C'- en4 <br /> C1 OTHER:T v'4 u1rdl`/ v(r' ❑OTHER: {, 1 <br /> APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS:A " r �_ i t,.dj CON�/TORCASING,PROPOSED <br /> i lr ( (BYES,list spedficeti in cof Section): t <br /> fsf� � � AlE3� A�1 C'�°�Ct <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> ' I hereby certify that 1 have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed 'r f`� O > C_ C_6 <br /> Title/Company f r,� 0r'`�7- ,5f <br /> Print Name / `�G- <br /> Date 1i/ 1�?!l`ro <br /> jj� � __ rr,, DEPARTMENT USE ONLY <br /> v <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `' --'E r R� <br /> WORK PLAN DATED: CU 91.1om!C„C J <br /> APPLICATION ACCEPTED BY / � DATE ISSUED C p <br /> AREA -1 "I 7 <br /> 1 GROUT INSPECTION BY FINAL INSPECTION BY <br /> DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: /16 •-L <br /> &ACCOUNTING ONLY: AID# FAC# <br /> S FEEINFO AMT REMITTED CHECK# RECV'D BY DATE ERMIT/SERVICE# INVOICE <br /> SR# 0 t,rr-77tQ <br /> C-57 WC -WAIVER <br /> C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5107(WEB) - <br /> . WELL PERMIT APP <br />