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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> r c Telephone:(209)468-3449 Fax;(209)468-3433 Web:wwwsiaov.ora/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 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 oVSar Joaquin County Environmental Health Department, <br /> Well Location �0'T'ttF.t^Bt tJnGL'I1� Cross.Street GINCOz2nK,ty, <br /> City �• Cj, =,,,.,L Assessors <br /> Property d'W2taF.� �ez1.1L*-tL162IP 2.03Owner CAlUr (�. L{.ry„� Address .,16f ri a-rt.1 r—. ZIP g52o2 Phone# 12 R �,(t <br /> C-57 Contractor clylcAr,F'r!p lrclWddress �+o'Sr7-I�+uu- <br /> - La' d.;.t. CitYf� Lic#11':<IDPhoneq. &Sq- I1� <br /> Consultant/Sub Cntr CSSAN•S Address3-91 '�-tLC�t gam, City �r ao frltt kuc# phone ft �Qt-�'?r}� <br /> Ot7 <br /> GIS Coordinates:X ,Y , <br /> To INRan e <br /> 9 Section <br /> WORK TO BE PERFORMED: <br /> *RNEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> SOIL BORING# El DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑❑ <br /> 1]WELL# T El OVER-BORE- _) MVti• '�)._ C]PRESSURE GROUT <br /> TER <br /> ®`OTHER {nU TC. GROUT SPECIFICATIONS <br /> COMMENTS: <br /> � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ty01 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE IOrIN <br /> ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:Z <br /> El EXTRACTION ❑.AIR.HAMMER/DRIVEN CASING THICKNESS' E£-D to TYPE OF CASING:0 STEEL\xPVC 13 OTHER <br /> 0 VAPOR ❑MUD ROTARY_ DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED❑AUGERS 9HOSE <br /> ❑AIR.SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:Yl Yes C1 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> "C—NF AT <br /> i <br /> ❑OTHER; OTHER: 1 _ _ APPROX.BORING DEPTH ,1{65(y'I �I <br /> CONDUCTOR'CASING PROPOSED BOLTED TRAFFIC BOX -e CI STOVE PIPE <br /> COMMENTS;}yrxn Liu U)(LGt.��rtuni+,.y�Q,��KQ,�;�� �� _ - (if YES,IIs4speMwlions in mmmem section) <br /> '1"rCN'>J44WtY q r '167nC, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING 1- <br /> I <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,antltl altl ic. leitornia Laws. <br /> Signed <br /> TitlelCompany fes• GEOt,oGr,fi ��{•Au{C.c <br /> Print Name Date BjLT/op <br /> DEPARTMENT USE E-QNLy <br /> SITE MAP IN UNIT IV FILE,ADD <br /> ?R <br /> WORK PLAN DATED:_ <br /> APPLICATION ACCEPTED 13 DATE ISSUED _ �e O AREA <br /> ^-�-- <br /> GROUT INSPECTION BY FINAL INSPECTION BY w/h DATE 7 tt B�_u'j <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> —= <br /> LACCOUNTING ONLY: i AID# T <br /> FAC# <br /> LElN AMT REMITTED -affEe nR RECV'D BYDATE PERMIT/SERVICE INVOICE <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EH029-01 11f"7VNFB) -- <br /> /'�^ WELL PERMIT APP <br /> �jJ.-K "V t 28gC¢D <br />