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ln�Is'�EU `AEU <br /> SAN JOAQUIN COUNTY : 2009 <br /> r <br /> G ENVIRONMENTAL HEALTH DEPARTM SITE <br /> Nz: �Q110ANTHEAWT`.; 600 East Main Street, Stockton, CA 95202-30 IGATION <br /> Tele hone: 209 468-3449 Fax:(209)468-3433 Web:wvvw.si4/Vf�tl-R�/��E <br /> \q'•.::':::..\P P ( ) 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 /> �{`�Q� S' P OV-1 WNL ( b o '15106 Assessor's y�-o <br /> Well Location AI1 Cross Street I�V�S�M Cr City SIl �T N Zip GS2oParcel# <br /> Property\/ 1' _ <br /> Owner YIt-Acc C�- Y(AoSo Address g804 S' I�`��t Y City"-T -1T0� Zip 1'52-G Phone#/(?"9 12z-?'q( <br /> C-57 Contractor Jo I(. q oYyf!-: Address 2S �' Y �T City TUL141V-C Lic#97 0-4%-Phone 1�5�i� wq-7700 <br /> ConsultantlSub Cntr Address 3434 "AU-ttJt AVE City Lic#PCT 5383Phone <br /> GIS Coordinates:X 'y Township N°T Li%ye� art US(SS Range Section <br /> WORK TO BE PERFORMED: <br /> Ig NEW WELL/BORING(CPT, EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> N SOIL BORING# &e*7-oY;:F- ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: I (, DPV--�r T�gj1 L& To �AK/MoM l�—1 T7 I of �T `�Et'hl Crlts`��b Sy�FfELc <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL So TREMIE TYPE TO BE USED❑AUGERS N HOSE PVC- e <br /> ❑AIR SPARGE/OZONE ;9 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:IdYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS c{(- C-e 1\CN-T &1(--T <br /> I <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH [IBOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:SoIL'Rsittlf.(CT oNLY• 1,4aW'c(y 1n1ST"Aua-T tots(, (3a�c,(�.FI�.�,� WrN r ;�kT <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 p abl liforn' Laws. C <br /> Signed Title/Company 't2(PI� fpr((ES we <br /> Print Name Date lzl�/01 <br /> DEPARTMENT USEONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY '21DATE SUE S ° AREA 36 L( <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 CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC t/ Q 1 -WAIVER C57 LETTER OF AUTHORIZATIONTO SIGN ERMI ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) V`L T cl_- LW 44f kw .D�Yi l O�(,� p v (/1p0� WELL PERMIT APP <br />