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r <br /> `'t \ SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s*gov.org/ehd UNIT IV <br /> .... <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 <br /> cCounty Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. § <br /> f 6 7S0 f���� /7 /' ss '�� ���/NO�✓� �� eop zip �farceAsses#rOb' <br /> Wel L cation Cross tfeet City <br /> Property ' -y 70s'p 6 <br /> OwnerS�g���/¢Q�/i✓ c�f✓u!✓Afd F �Iry Zip �rPhone# <br /> ,1r",W4 '—�c2 6 <br /> 371_(7 � / /P� .. _ cit/ylrT%N�` O d4 <br /> C-57 Con ct Address y Ic on <br /> Consultant/Sub Cntr 'y / Address/ City Lic# Phone <br /> GIS Coordinates:X X GYeG' Y /01 P �,Township 2 ��f� Range Section �1�r��i�� 7 <br /> RK TO BE PERFORMED: <br /> IEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') F1 DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# /3?L✓�'.�— _ [_1PRESSURE GROUT <br /> 'OTHER GROUT SPECIFICATIONS / /✓% <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEACATIONS <br /> MONITORING HOLLOW STEM O• - DIA.OF BOREHOLE _ <br /> ❑MULTIPLE CASINGS El WELL CASING DIA: <br /> ❑EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS��� TYPE OF CASING:❑STEEL)(PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL i3S TREMIE TYPE TO BE USED❑AUGERXHOSE <br /> ❑AIR SPARGE/OZONE El PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes,/❑No (NOTE:MAXIMUM FREE-FALL DEPTH,IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: El OTHER: s�,A9PP9ROXT.BORING DEPTH 5 ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> COMMENTwe IVS- c�,PU�/i/� /y./f`'.!t'�.C' v'v//®��OR I $OPOSFQ� (if YES,list specifications in comment section) <br /> NOTE: OFFSITE 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 a the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable Califor is La <br /> Signed U(/ �;�E�!f K ! Title/Company -i',/✓ L;760 al/L/ 1_4 2-41V' <br /> Print Name <br /> /✓ e4445'01;0i e-:_4 e�AiP4!�71— Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,AD RESS:, NU 12 3 2009 <br /> WORK PLAN DATED: 2 ENUfR ! <br /> APPLICATION ACCEPTED BY � /C DATE,IISSSSUED <br /> GROUT INSPECTION BY w1 • Z� ���/�"AI'- FINAL INSPECTION BY /" � 1;6TE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR#,251�3 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />