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utK•.co v 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.sioov.oro/ehd UNIT IV <br /> CtFOR / <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 /> Well Location 107. 4. v•ISov� 0Cross Street Ma'ke4 S{+•'Ce+ City 00, -1-gn Zip S_2vS Parcel# 15S026t(5 <br /> Property 1 <br /> Owner TA S n rv` Akt%i-a! Address )Sl `I C. Mw-ke {' e4- City S'I"u C� I P>7 Zip qS2 OS Phone# <br /> C-57 Contractor TE tr Address tl35'8 monitr N4, Place- City R...oao cwd ovg Lic# 76101b$Phone 6I08-S3-b"010 <br /> ConsultantlSub Cntrlrrewd tta A,.14v'Address 011I r - - Sf. City Escwlw. Lic# Phone�.4)$38---/g- A- <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: .� <br /> ❑NEW WELLJBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑ DESTRUCTION(CHOOSE TYPE BELOW) Q <br /> SOIL BORING# ri lrl,S V Z.41.T 3 r SV 4 1 S(r.& 5 L, b ❑OVER-BORE DIAMETER N <br /> WELL# ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE TI4 I 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:/VA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS NR TYPE OF CASING:0 STEEL 0 PVC 0 OTHER Q <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL S THEME TYPE TO BE USED 0 AUGERS 0 HOSE ('+ <br /> 0 AIR SPARGE/OZONE FPPUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 Yes ®No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> •SOILBORING 0HAND AUGER GROUT SPECIFICATIONS NP..� CC+- *- qv"A-- <br /> 0 OTHER: 0 OTHER: APPROX.BORING DEPTH S ' ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASINGPROPOSED (if YES,list specl8ptions in Dammam sedicn) <br /> COMMENTS:S.:\ bw:.^gt aAv w+�ced io SI F-v er att_ pf- [ollQc%:..w��. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS ILI <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`aprplicable California Laws. <br /> Signed �'C_ VNO Title/Company 5+O`FF Cr l e e i S"� lr r0�✓t t) Z t�o <br /> J. y <br /> Print Name J \J401147— Date Z ; /a°� S <br /> r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I UZ S, (,J I�SOa --"-J �-}�- fon[ C.4 9:5Z65 <br /> WORK PLAN DATED: 2S '4era ( GO.9 J <br /> APPLICATION ACCEPTED BY 4111 rdG�S'r? DATE ISSUED / AREA 575 <br /> GROUT INSPECTION BY �{/ FINAL INSPECTION BY i(/Gr /Y DATE / 3 <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# I INVOICE <br /> 41 00 o/3a69 9 Ry 09I SR#0058461( <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGA PERMIT ENCROACHMENT DOC <br /> EHD 28-01 11/5/()7(WEB) W ELL PERMIT APP <br />