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�--" • qc' SAN JOAQUIN COUNTY %, ?t ENVIRONMENTAL HEALTH DEPARTMENT SITE �e ;f 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3449 Fax: (209) 468-3433 Web:www.sicIov.orq/ehd UNIT IV N;p. <•F o WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County r>a-=I--n-g1t Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. .�y_.�� ,1 t Assessor's 3�� Well Location �P p Y� Cross Street I✓�N��--r�1 City Ca%tj�C7J Zip 85203 Parcel# t3�-.6-/-V- V I Property OwnerVMA/ AddressPO•BDl.�'Igs cityS''%ClezO Zip% 4 Phone# .WtW lifeP 0 ^"'R• C-57 Contractor CAY.Ao&M1 UrJn Address 3032.OMEf C19Com— City k6gL&W GgP og 1p qc-z O Lic# /�1,Phone ml(p)w Consultant/Sub Cntr4gAt.Yf�t.. Address�I-+ lr .E l L.95,OVtb SO-- City�P-AN(LHo(oft Lic# Phonet-q t'4)vaii0"FPID GIS Coordinates:X ,Y ,Township 1 Range LQ C— Section 10 WORK TO BE PERFORMED: 'NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') [I DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# El OVER-BORE DIAMETER ❑WELL# 'f0D S SOTAL ❑PRESSURE GROUT f7J'OTHER 607410, GROUT SPECIFICATIONS COMMENTS: p�,,,,�, / TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS" /.K w• -rvaut� tfi �l1 1' MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 4&2 ❑MUL1T11III�PLE SINGS❑MULTI-LEVEL WELL CASING DIA:_ ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS r]!hd1(G ,C PTYPE OF CASING:❑STEEL X PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL*-Afla—kfAT REMIE TYPE TO BE USED❑AUGERS ppb HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH/IIS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS � ❑OTHER: OTHER: �_lutC> APPROX.BORING DEPTH t'TO� tl"�TD,A❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE �7e CONDUCT OR CASING PROPOSED (if YES.list specifications In commani section) COMMENTS: ® WaLue ytytrn IAds, �tr.� % AIN b¢. �nvn�•.�.-A lt4w)n jt Cir Ics= in sena- 49er <d W wwtu> 2avvt, tcvjer VAO rv1 Z.o�t- NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and all applicable Cplifornia Laws. Signed ��!•—t.-s-• _ TitlelCompany r%P-6 04- trrS 4 0-r-,17' Print Name L`s. 3 <C,c+n.£ rJ.r pt Date T`tT f" , ,,,DEPARTMENT USE ONLY If , SITE MAP IN UNIT IV FILE,ADDRESS: I XX>- " - j °"`^•-"� `^"tet "' WORK PLAN DATED: f APPLICATION ACCEPTED BY�y1/1 DATEIS UED �^ AREA GROUT INSPECTION BY /i t FINAL INSPECTION BY / DATE DESTRUCTION INSPECTION BY DATE- COMMENTS/CONDITIONS: illy ACCOUNTING ONLY: AID# U FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE a o 3 �R- o 5 1 SR#s 90 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2941 1115107 WELL PERMIT APP