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SAN JOAQUIN COUNTY <br /> r: <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.sigov.org/ehd UNIT IV <br /> c� <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 /> //��w A/lA Rpur�33 1 JRnn VERNAL 1 `� Assessor's GS <br /> Well Location���l' F� Cross Street .. 'JEL7�/2 ✓ .- �Ity S Zip 5.7�''S Parcel# <br /> Owner Wer— l N,RUSTaPJ Address fQ J S--1pz ���Lvn; city T9AG`( Zip 15'3-7L-- Phone#L�-82� 33 <br /> C-57 Contractor_ksI dplu vL-j Address 220 N• EHSi S1eZF` cityWnZiip q63 ic#X�P o�-� 4 <br /> Consultant/SubCntr Sf��L. Address A00 h/- f4;4C• SVflfZCity 5)4Cf:H1`ll✓r� c# 'f— Phone9(0'�79"b7C15 <br /> GIS Coordinates:X Y Township 3 s0 f/- RangeIfr'00 57- Section <br /> WORK TO BE PERFORMED: <br /> [Ii <br /> NEW WELL/BORING(CP �PR—O6HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# n OVER-BORE DIAMETER <br /> WELL# -;PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS E TCgN►ienlf <br /> COMMENTS: Z' CieOP90115 8001'JC11-S (U <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS /\ <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE-".—-> El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: PSA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS A TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> 1 <br /> ❑VAPOR �❑/MUD ROTARY DEPTH OF GROUT SEAL I D r NO TREMIE TYPE TO BE USED❑AUGERS VIOSE <br /> ❑AIR SPARGE/OZONE Q�PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes)A No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> /SOIL BORING El <br /> ///❑"`HAND AUGER GROUT SPECIFICATIONS ry2E 1AT GEI"1C f I <br /> 119 OTHER: Il'1�f t7 Y ❑OTHER: APPROX.BORING DEPTH J`5' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _ (i(YES,list specifications in comment section) <br /> COMMENTS: W r LL I-t ti V ' L 1 ���51}2uCjL`R' O F A PQ t'A��=F> <br /> ;p w OVC- A5 ,4 <br /> NOTE: OFVSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have pre red this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and I applicabl Valfornia Laws. j <br /> Signed Title/Company Pk,UAF_Cr G JVIQuNNnP I�CI�NNTtS� gAt <br /> Print Name LAP-0 SI L V A Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: r W� L• ' ✓ !' <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED Y DAT EEr �� r AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY O� DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 16, <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC -WAIVER C LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5107 WELL PERMIT APP <br />