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SITE <br />MITIGATION <br />UNIT IV <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEIN <br />600 East Main Street, Stockton, CA 95202-3029 !;•c!, - <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sjqov.oriid <br />ZO.rPewsw,,s COMMENTS: f-7 t:tri.,L',‘.2 13064 /J4, s 1 <br />PERMIT ENCROACHMENT DOC <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDENVIR CiNMI: <br />F.V 0 <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 />Assessors <br />Well Location 5611 '&7. W•krEiz-LiT) Cross Street OVER kt-VseR. City .51-0c-v--ro tj Zip CO- /5- Parcel # 42E3 -4 - t <br />Property <br />Owner 5Ak.A. Address qq GAte-LJL Lela•e. City 's-roc.oc---r-0 <br />C-57 Contractor 6oiL:Paotsc- Eric- Address <br />Consultant/Sub Cntr Address 57)-3-0 1--1 • 114.'771 57- 1445-a City <br />Lic # t3R• '1•Phone <br />Lic#K-.961-3 Phone -S-`1. -gd5--/Vs-/r <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS .-------' TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br />0 AIR SPARGE/OZONE 0 PUSH POINT / POR CPT) GROUT SEAL PUMPED: 0 Yes No (NO_T_E• MAXIMUM FREE-FALL DEPTH IS 30') <br />%SOIL BORING 0 HAND AUGER GROUT SPECIFICATION .ge.‘170ia 17E- c-tuP g -16 72-- 1 0 u•tV!.5. CAIIEVr <br />OTHER: 0 OTHER: APPROX. BORING DEPTH d &,5 ; à6.' ' 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING rF.z.ec.,:Rj) S E D pi YES, hot specifications hi coin ment section)COMMENTS: EX/O/A rd(4-0 ry 104 rirkp YYlusi- 6. .3 r a_Li-t- tAl ----be-4,1-.5rk b r ce_yrke4-1 5 1 v,rri <br />NOTE: OFFSITE OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: -Aaa-bielaerrxi rt_ r fiwidc) prcr-Lerf Or ins,ecbev-t, <br />here-ht rvi_ re c_r-/ e <br />_s <br />• j et con et, e r ro rt <br />ACCOUNTING ONLY: AID # <br />. ti() <br />FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />=-, <br />//9-F/d SR# -5‹.1/64/ iiM'50 <br />OPC412— Ci.,-/L40/ da..„tuee WELL PERMIT APP <br />6(11-e7-574`---"-,1•Kerl-W,0 <br />City I <br />EHD 29-01 116/07 (WEB) <br />69 Yith4 ( <br />Zip `SD-1.T)- Phone #'5*- <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED:(Th., <br />Z NEW WELLJBORING (CPT, pEOPROBg HYDROPUNCH, HAND-AUGER, OTHER*) 0 DESTRUCTION (CHOOSE TYPE BELOW) 0 SOIL BORING # 4/' "g•r1-11:27i 5 - DOVER-BORE DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *OTHER GROUT SPECIFICATIONS <br />DIA. OF BOREHOLE <9.c " 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />Signed <br />Print Name E-LC6 ty <br />I hereby certify that I have prepared this pplication and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applic2,C •for i Laws. <br />Title/Company '7441Je1-r- -5;&X/2,4 47-)FT-771- afiCgc-,^11 <br />Date (-c)- <br />ADDRESS: <br />BY DATE ISSUED //7/3 9 AREA <br />FINAL INSPECTION BY DATE 43-/c>7 <br />SITE MAP IN UNIT IV FILE, <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED <br />GROUT INSPECTION BY <br />DEPARTMENT USE ONLY <br />lp II (Ale; lea(