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�o�g_" 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 /> 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 35500SW11�I Cross Street 1I1611AWAY33 City VEI2NAUS Zip 453SS Parcel# 255-2(oO-03 <br /> Propety Owner ,4C140LIP BELLINI/ r- E6N <br /> Q ELL!NI Address 4,10 W. DU�,4M FEQRh'RD city TRAG Y zip q5 0 Phone#201-83/0.9109 <br /> 530-"-242¢ <br /> C-57 Contractor RY1 D2ILLIN64 Address 2-20 N.EAST SVEST' CityWOOMA,NIP zip%7710 Lic#802-3?4 Phone <br /> Consultant/Sub Cntr $A IG Address 3800 WATT At4E-1 SU We 2jOCity SACRA M r=WrO Lic# — Phoneq Ib•cn-i•3i-95 <br /> GIS Coordinates:X Y Township 3 SO tlrH Range b EAS Section 3'6r <br /> RK TO BE PERFORMED: <br /> NE WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# T QOVER-BORE DIAMETER <br /> Lj WELL# PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS N6AT'CffM <br /> COMMENTS: GEOpRUr3E 130eINCh <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3 4510,13 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:NA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N A 1C TYPE OF CASING:El STEEL El PVC ❑ OTHER �JA <br /> El VAPOR [3 � ✓ <br /> MUD ROTARY DEPTH OF GROUT SEAL 'a 3S" TREMIE TYPE TO BE USED❑AUGERS16HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> K,SOILBORING El HAND AUGER GROUT SPECIFICATIONS NEATGEIM6NT' <br /> �OTHER:W ITEMN4112Y ❑OTHER: APPROX.BORING DEPTH 3S' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> (� �+ nl l'� I L COND CTOR CASING PROPOS D (if YES,list specifications in comment sect n <br /> COMMENTS: AEOPRO t pN L NAVE�MPcV e LL 15 �OtJ�SMUUMEQ 6�A <br /> �1✓�K� >=I i-TE E lP\7ZCAS-I tJ C-1 . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I��_ <br /> d�() _ <br /> ith San Joaquin County Ordinances,Rules and <br /> Regulations,and applicable Cali rni Laws. (� <br /> Signed Title/Companyr I R t''�F�ON,C{�L�C NC 16T &AI <br /> Print Name L A Q 2( 1 LVA Date (0 {�I O C.> <br /> ( 'DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: KJ 27 J <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED B 14 DATE 1 SUlf D 7 7 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BYU 0 DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 010YI1 f f1 Y— " 0r 72 b A7 l'c� SR# 13,00cG7 <br /> C-57 WC -WAIVER CW/LETTER OF AUTHORIZATION TO SIGNE MIT ENCROACHMENT DOC <br /> EHD 29-01 11/5107 WELL PERMIT APP <br />