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n � y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.orglehd UNIT IV 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 applica' is made in compliance with San Joaquin County Develoom nt Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Departm . SIX I A5• 2uek,�,irno.•� lQ ssoes Well Location Me-DONALI) ISLAND cross 3ireet N- 'Zou-ERHAN Rte City UNI NKC)RA Zip Parcel y©3c�1©9 Property Owner il*IiFIC &ASif E LECT-1?#C -_ Address_"p,I,r_i Vi4V CANYAM J20 City 8t iy',& 17L Zips'#_,_. e �._Phone#915-4115 1. -3si °-ar'_t- C-57 Contractor tZ5Z QIZ 1 t_L l & Address` City W OC>OLANLI Lic#802331 Phone S3O-(6E;A-2-,4.21 Consultant/Sub Cntr H5 6t2CUP Address 30?, pEJU►)LC ro N 1ZL). City OAk- ANON Lic# Phone-50-3e 3—9E[�d GIS Coordinates:X .,.1 Z/ -1900 , ,Y Township 214 Range Q E Section 2-1- WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") M DESTRUCTION(CHOOSE TYPE BELOW) r SOIL BORING#_ ❑OVER-BORE DIAMETER a WELL# ___ 04 PRESSURE GROUT _ ____ E]'OTHER _ GROUT SPECIFICATIONS,9�SACK X C V ry 7 T C k a1r COMMENTS: HCW17L't•°ikJC vvE"r, t-4tiV-ili?Q -Z -3 •1f 'G,-1 -E"--9 tOy� PiF7CMEtF12S eAA, -IT,A,-3lA, '3A . -SIA, -3A. -7; TE►'9s'ctrmit Y PiFzrHCTL-- RS rt7t-I -2. ---3. _4 -..S TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS N ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROV. SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT IGP OR CPT).___ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER ___.._.._._..._.._.._...-_.___.__ ❑OTHER: ,_..._.._._...._..........._.....__-.._...._ APPROX.BORING DEPTH _�._ C1 BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list snecfications in comment section) COMMENTS: 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 California Laws. n Signed Title/Company PROCoRAN NANA6E1? N ) jGj?0 Print Name _ Date 7 2A I u �}, , DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 4"�s I (�l�c.�l-��+t R�. e . b s L 1)G kx�c✓�d ��q ►Sal WORK PLAN DATED: V—F F,_ - /-oo taa«/� /JCUQ� �—w_�_I APPLICATION ACCEPTED BY _T p TE ISSUED AREA.,=/n (17*17 GROUT INSPECTION BY _ _ FINAL INNSSP C,TIIO BY- DATE DESTRUCTION INSPECTION BY DATE ( /7�y COMMENTS/CONDITIONS: wS a�.JE vsCA ACCOUNTING ONLY: _ AID#_ FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE (0O- l�$1 7/3v s9 SR#6051 jA . C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 1115l07IwEB) WELL FERMI r AFP