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SAN JOAQUIN COUNTY <br /> ;.••mac-x�•.o� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> F A-2 i `• SITE <br /> ' __• ' 600 East Main Street, Stockton, CA 95202-3029bl <br /> MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:uvWuvs Ov.Or Iehd <br /> — UNIT IV <br /> WELL PERMIT APPLICATION <br /> II'l NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appilcatl o 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,chapt 9-115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> Well Locatt n Ocross Street 010,5'L Ave CI t � ry Z Assessors <br /> Property ly 3Parcel# 14 1- So-Oq <br /> Owner Address City Zip_ Phone 7AS) - x <br /> C-57 Contractor ow bli lhn Address P 0- Box 470 •_ City ; Lic#7A0_ 90k Phon dog) 369-9&00 <br /> ConsullanUSubCntr_r:N&E0 Inc. Address S20 N. WIIrms Ave Cpy R{Qar1 Uc# tJfd phone o 83s-05Glo <br /> GIS Coordinates:X Y ,Township Range Secltan <br /> fa 37.9014 Lon. -1-A1. 310 <br /> WORK TO BE PERFORMED: <br /> I9 NEW WELLMORING(CPT,GEOPROHE,HYDROPUNCH,HAND-AUGER.OTHER-) ♦]DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# [a OVER-BORE DIAMETER <br /> ®WELL# MwIK.. eJr Mwl7-10� (]PRESSURE GROUT <br /> Lj-OTHER rr GROUT SPECIFICATIONS <br /> COMMENTS* Surveva� �ss�il rw�rs wi ll by Pufo1�5�1..1 ..n IJII[_ �ar►aD1rf ia4, r'r•�orl- <br /> TYPE OF WELL INSTALLATION TYPE CONSTR LICTION SPECIFICATIONS <br /> CA MONITORING ILHOLLOW STEM DW OF BOREHOLE IO_;n• ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING D1A: W„ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Scl%, 4a _^TYPE OF CASING:❑STEEL iR PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 1 O TREMIE TYPE TO BE USED ISM AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes Ix No (NOTE:MAXIMUM FREE-FALL.DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS dq k Ce,r►1ev,V <br /> ©OTHER:_ ©OTHER APPROX.BORING DEPTH LI }. 19 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: A4...l 9-1ft Cam S"a4'an w,LIt <br /> IT, <br /> CASING PROPOSED No (N YES.NO spoeM=11ons In eommenl Sodon) <br /> 1-- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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 app c e lifornia Laws. <br /> Signed rr Title/Comtany.._ lLeAloa iq4 ISAY, <br /> Name f <br /> Print o 'C.�-aetl Farr Dale x oa 9 <br /> A DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: // <br /> WORK PLAN DATED: rp�I �Q <br /> APPLICATION ACCEPTED ByDAT SUE 6'o AREA g <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE -0 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO ANT REMITTED CHECK# REC 'D BY DATE PERMIT/SERVICE# INVOICE <br /> R#� <br /> C-57 V WC wr -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> E"D 29-01 111507(WEe) <br /> WELL PERMrr APP <br />