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Pq�rN,. SAN .JOAQUIN COUNTY <br /> l : Da ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> IL9 .K <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 7 Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd 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 construbt 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 Assessor's n <br /> Well Location Gj25 w,W�_ Cross Street LNWWJ Ctty gTOLl-fOtJ Zip 0152.03 Parcel# <br /> Property QGWS nn� <br /> Owner ws'rc'Q.--PF-01308 1� Address 50t � Q"S'S60 City STY7Ll�Tptl Zip 2�c+=•. Phone# a��Gs�2 <br /> t7W N6P-S�SOr=µYT tON <br /> C-57 Contractor CASLk0r,-1 -tOLfN�+1 Address ���!7 DN1EG!'.t Rf l.F: City Q+LJLNo(kjAglRZip 2.Lic# Phone����y <br /> Consultant/Sub Cntr"VTA14fet, Address lom K.&LEngpe, f7•D — City P-6my�rRGal,4 Lic 0 Phone(u)g0I•DJI£D <br /> STC- I00 ,( <br /> GIS Coordinates:X Y Township I`+ Range, ,,c� ._Section <br /> ID <br /> WRK TO BE PERFORMED: <br /> El DESTRUCTION(CHOOSE TYPE BELOW) <br /> NEW WELLIBORING(CPT, <br /> SOIL BORNG# ElOVER-BORE <br /> [IIDIAMETER <br /> ®WELL# N # T%A El GROUT <br /> JQ OTHER <br /> RC GROUT SPECIFICATIONS <br /> COMMENTS: / / 1 - <br /> y F // Q/rt !2/ letTYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �,'/ b p1, <br /> MONITORING [I HOLLOW STEM DIA.OF BOREHOLE [I MULTIPLE CASINGS 13MULTI-LEVELWELL CASING DIA: Z <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 4tftb 80 TYPE OF CASING:❑STEEL XPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS, HOSE/ <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:k(Yes ❑No (NOTES:,MArXXIIMY-UUM FREE-FALL DEPTH tS 30) <br /> El SOIL BORING CI HAND AUGER GROUT SPECIFICATIONS <br /> OTHER:?0�I1 APPROX.BORING DEPTH 3 H`SOS 1�+N of ,3 to[I BOLTED <br /> TRAFFIC BOX OR ❑STOVEPIPE <br /> ❑OTHER: ! CONNDC�CTRpR ISAQ NG PROPOSED `, (if YES,list specifications in comment section) <br /> COMMENTS FtPM7 <br /> lSy*wt e_Cal Vt'd,y� 0. W <br /> IA6" {ylt Wv�at c�W Z6 <br /> NOTE: OFFSITE BORINGS REQ IRE 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 applicable <br /> /California Laws. <br /> �� �iy lam._`-- Title/Company `<`rr dk Grk4o<Jr /,j''1"'t�5t — <br /> Signed .� -� v/ <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS •ob <br /> WORK PLAN DATED: J 0� <br /> DATE SSUED !O d AREA <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY <br /> "P FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY- _ _ - DATE <br /> CO MMENTSIC O N D ITIO NS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> oZ 7q?230 '1�4 (D SR-- <br /> S�l)5 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN Hfllll ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 2901 11/5/07 <br />