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�ot'` �•.c SAN JOAQUIN COUNTY <br /> Z ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> y Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s*gov.org/ehd UNIT IV <br /> 4�IFoa�'� <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 Countyre <br /> nmental Health Department. <br /> Assessors R i G--f 7- <br /> 0 <br /> Welt Location 35100 Niq�Lcl a y 3Iss Street fcity /lal�/ S zip �`5, 85 Parcel#Hi6Nl t/Ay 33Pro01 <br /> - <br /> Well <br /> Cczifraki-s AddressT �C /D�l�/ ZG 0 1. City c<kfo k1 Zip 15 2.0 Phone# qOq 9 g'3 ,5( <br /> C-57 Contractor 0 ft' rl ; dress 1 Z SO r i/r i �' , v lc-q City zip S 7 X Lic# 0 t Phone 530 <br /> I� loi-3La� <br /> Consuttant/SubCntr�QhVlQvyt-SA Address[DD0/3r0 � t� ikLcty'f Lic# <br /> `` Phone 55 to <br /> GIS Coordinates:X Y Township Range Section <br /> RK TO BE PERFORMED: <br /> ANEW�LLBORING(CPT,GEOPROBE,HYDROPUNCH.HAND-AUGER OTHER•) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> _ <br /> u SOL BORING# 'f!Oo 6evPR ol3e SorL XR-/A.Y5 0 P ER-BORSSURE GROUT DIAMETER <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE jj ,�r nA❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS 'v TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> [I VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL%f4 ell EMIE TYPE TO BE USE [IAUGERS' HA9E—P VC <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes [I No (NOTE::MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS I Ori/4k'4 CL''YI&�/ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S(] -CQ e'r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (H YES,net spedfica... In comment sedan) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certifFth I.ljraye prepared Is' icati�r �nd that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, lya,poli�abie Cal <br /> lr, <br /> Signed ,' Title/Company <br /> Print Name I owl l ow I Date <br /> ff DEPA{R-TMEpNTI USE ONLY <br /> SITE MAP IN UNIT IV FILE, DR SS: 7 S� l /�e �' "� e� (S <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED l U AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHCCK4 RECV'D BY DATE PERMITISERVICE# INVOICE <br /> '�-9 05- 99 - 3�- 07C,5 1G (,Ll�- /b SR# 607yq <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 10/pg/09 WELL PERMIT APP <br />