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SAN JOAQUIN COUNTY ILCIhL�UL U <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 MAY 22 200MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: wwW.sjgov.org/ehd PT IT IV <br />EIVIKNIIJENT HEA—, <br />WELL PERMIT APPLICATION PERNlIi GRIBINAL <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 s8 <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ZL 1 150 41 <br />z Assessor's <br />Well Location 33N � �^ si: Cross Street �a /A 10 k-� City D Zips 366 Parcel # <br />Property$ nWq G k o CA TRI STI; E TAL 0 Qoh r440o L o S AAJ gPGS 900,59 �iJrl S o o� <br />Owner Address City ..yea ZiPhone r�- <br />C-57Contractor Vto Address p,0.5o,c�t7G City Loll Zip 497-Y1 Lic# !ZA90'{ Phone Iro <br />Cons ultanVSub Cntr HiQ Q Address _'7,o06 oyrorf. n:4_ Dr. City 9o5Cu6 Il,- Lic # Phone q((o'&7? *Afb-7 <br />GIS Coordinates: X , Y , Township Range Section <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 4 wt& -:fti <br />❑ WELL # ❑ PRESSURE GROUT <br />❑ *OTHER GROUT SPECIFICATIONS 261+IR,d 1f/r <br />COMMENTS: be'Rro-1 I V �W n1 wells <br />TYPE OF WELL <br />t4 MONITORING <br />❑ EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />❑ SOIL BORING <br />❑ OTHER: <br />COMMENTS: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED ❑ Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ HAND AUGER <br />❑ OTHER: <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH _ <br />CONDUCTOR CASING PROPOSED <br />❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />. (if YES, list specifications in comment section) <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 gppncable California Laws. <br />Signed <br />Title/Company S' kff <br />5c;e-, ,) f <br />1 6 (Ziq <br />Print Name gen; G, in Sit <br />r"' . 44f <br />Date <br />d <br />Z-1 �� D <br />DATE PERMIT/S INVOICE <br />3502- <br />60.00 <br />DEPARTMENT USE ONLY <br />302 53 <br />Leif -WL <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />*334 / V 1 a 1 Yt Stneat at <br />Main <br />�K O <br />Y\ <br />WORK PLAN DATED: <br />20 0 <br />APPLICATION ACCEPTED BY V 41 <br />� , Y i 1- I ' `G �a Y 1 n a V/ <br />DATE <br />$ 0 0/� AREA �� <br />GROUT INSPECTION BY Iit,46 <br />/ISSUED <br />FINAL INSPECTION BY V I Ui�r�ct, <br />L, A;t*ATE `-47 <br />DESTRUCTION INSPECTION BY Yj�,` <br />"" <br />y% d��iyllftt DATE IJt)IZ t �jl� <br />P 16 <br />16 <br />Z 00 9 <br />COMMENTS/CONDITIONS:'De_ '+r <br />U[+1 Li., '4 L w-�j �Tl ✓SS <br />-s-'D' J --L <br />S 1 D •citrcr^ 8 <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE PERMIT/S INVOICE <br />3502- <br />60.00 <br />40• aD <br />302 53 <br />Leif -WL <br />5 30 SR#00543!7 <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT—ENCROACHMENT DOC <br />EHD 29-01 11/5107 WELL PERMIT APP <br />U� <br />c� <br />'01 <br />