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°Pa " SAN JOAQUIN COUNTY <br /> � art Qo? ���n�,l <br /> ENVIRONMENTAL HEALTH DEPARTM V ILIJ%/ <br /> SITE <br /> y: 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> MITIGATION <br /> �P Telephone:(209)468-3454 Fax:(209)468-3433 We a�w_���ps�{/jp �p_r�p 'T2010 UNIT IV <br /> gCikoR� - . CI4Y�ll�l�iytr�•(�!! 1-! <br /> WELL PERMIT APPLICATION Eal Tu <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEID/5� ���CES LTH <br /> 1 <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 9-11115.3 and the St ndards of San Joaquin County Environmental Health Department. <br /> 7720 6- /Ti�i"/✓�y ,J/ 9S—>O�Assessor's � <br /> Well Location Cross Streetpp City li� Zi q Parcel#Property SSL <br /> Owner ✓0'¢Q��^��7�Address�O�y 1��2 �/�ity S/���i"" Zip /�W�Phone -Zd9 ¢6Y--�o 6 6 <br /> C-57 Contractor ��«1P11uAss `9SO A"7y (5 '� City�A0-/'0'El'Zip 7Y rS"3Lic# 9'fl Phone <br /> Consultant/Sub Cntr __ '_i 4ddress City Lic# Phone <br /> !L <br /> GIS Coordinates:X CY Y A;1/ 010117 �T Township -2 N �� Range Section?//�/✓/e8� <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> 50-OTHER- GROUT SPECIFICATIONS <br /> `V /i✓ !i/Et'L ❑EXPLOSIVES DETONATING CARD <br /> COM ENTS: �„��l6—S8 S//'t7"GLU7'✓ P�U��: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESSa r TYPE OF CASING:[I STEEL PVC [I OTHER <br /> [I VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL ���O,tF�TREMIE TYPE TO BE USED El AUGERS[3 HOSE <br /> [I AIR Pe <br /> No SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:' Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ��'i✓jv/✓iTCs <br /> ❑SOIL BORING El HAND AUGER GROUT SPECIFICATIONS / <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH !��� ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. S�G�/��j� `C�J�//✓�E'/e <br /> Signed /�J Title/Company ScR"-) <br /> Print Name elf V" L Date y / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: yW41119 <br /> APPLICATION ACCEPTED BY ' DATE ISSSUU'ED //y�/y AREA <br /> GROUT INSPECTION BY ,�iL�(e�i1' FINAL INSPECTION BY R✓ � � '- ATE `r /0 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 4j If--r/ sr fir•CO �m.11t*S� SR#af 973' <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />