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r <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> RI 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> 4<iro5el/ <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 San Joaquin County Environmental Health Department. <br /> �'• Assessor's <br /> 62 <br /> Well Location lK Cross Street � IIJLt�L1J City S��17 Zip gS203 Parcel <br /> Property <br /> ep - <br /> OweCtN ocvrm lfro Address 121City 0K-"0 Zip qSM Phone#?VCi�•�S <br /> _ <br /> C-57 Contractors At)eyLW4Ass "3Q59-0INNI116 <br /> AIE-Cxe CityOQeM.`(['klo Cxegtq Zip 063—M-Lic# Phone(116) <br /> Consultant/Sub Cntr�'CAi�"f'�!_ Address'-/01� kILG1olRE 't�T> City T-rw�.0(nGat]IgLic# Phone 0lte)vel-04tH <br /> S4E lup <br /> GIS Coordinates:X ,Y ,Township Id Range Section <br /> ,WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> Cl SOIL BORING# ❑OVER-BORE DIAMETER <br /> 91 WELL#10D � T ?A 1:1 PRESSURE GROUT <br /> N'OTHER 1JIC GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONSl� 7c=(rC1 <br /> X MONITORING ❑HOLLOW STEM DIA.OF BOREHOLSMO@!� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Qiet> $D TYPE OF CASING:❑STEEL PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL SSE Ant PLtOTREMIE TYPE TO BE USED❑AUGERS HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:VyYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING [:]HAND AUGER GROUT SPECIFICATIONS ;.IEfkl f�ILdF-l�]T <br /> y 1p 1 <br /> ❑OTHER' Ny OTHER: Cn1�S l( , APPROX.BORING DEPTH YnSO RYe�YU �i ❑BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED' --�- (it YES,list specRicetions in comment sedion) <br /> COMMENTS: .i h Abe d S <br /> ml ec vJ beam q tare- <br /> NOTE: OFFSIE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 applicable <br /> California Laws. <br /> Signed iJ `-� Title/Company <br /> Print Name �Ia�J {c F+w.sa,.. i'i- Date `7/3,/3f, <br /> DEPARTMENT USE ONLY Qq)� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> "'�"' ': �-p sd- �"'"""'�" ' "�'��'`` " <br /> WORK PLAN DATED: J D <br /> APPLICATION ACCEPTED BY � - DATE I SUED -7 AREA /y <br /> GROUT INSPECTION BY 8 v� FINAL INSPECTION BY DATEy �Ll <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/C ON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN IbERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 11/5107 <br />