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ip <br /> 0 SAN .JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd MITIGATION <br /> WELL PERMIT APPLICATION IN�dfM <br /> NON-REFUNDABLE PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED , 1 I 7 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicaion is made In ml 2 L 0 iU <br /> Joaquin County Development Title,chapter 11115.3 and the Standards of San Joaquin County Environmental Health Depa c ��f�c <br /> Well Location 14255 SOUTH AIRro41 WAY Cross Street _LATH P P If1 <br /> Property �' ROAD Ci HAN-Je GA <br /> Owner yBCCI PTP ry Zip ssso � �'µ <br /> Address 1q 12 E:faT VErw oN AVE City VE2N� ZIP `1orrtt Phone# <br /> �Mi01JP WaY <br /> C-57 Contractor ALL WE, haANCON1stNT address 69(¢2(o Q <br /> /1 Clty1.)NH-09 299 wZip 95(019 LIC# &499s� (53pM95 <br /> Consultant/Sub Cntr Gz/� Phone <br /> Address 10160. TRAOF GEME2 eR 1"07 16(94 <br /> ��Clty RwvtHo fo4paa Lic# 5 Phone RjIlQKB9-4y00 <br /> GIS Coordinates':X� �a532os ,Y_ y Igg�yy ,Township �1 S <br /> WORK TO BE PERFORMED: �— Range L Section 2�{ <br /> ®NEWI qWELUBORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) <br /> MLSOIL BORING# Torti` -not,., cn ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑WELL# ❑OVER-BORE DIAMETER <br /> ❑'OTHER ❑PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: 11EXPLOSIVES DETONATING CARD <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING X HOLLOW STEM DIA.OF BOREHOLE ~ <br /> 111 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS. S!/6 <br /> ❑VAPOR TYPE OF CASING:E]STEEL ❑PVC ❑ OTHER <br /> ❑MUD ROTARY DEPTH OF GROUT SEAL E TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:[ Yes 14 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING El HAND AUGERGROUT SPECIFICATIONS '� <br /> a f ^° and .1 "y,�n4 Gro 76*, a wrct�c <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S To I b Fe6T <br /> COMMENTS: CONDUCTOR CASING PROPOSED ❑BOLTED TRAFFIC BOX OR EI STOVE PIPE <br /> (i(YES,list apecRicslions In canmenl senlon) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WOR KMG HOURS NOTICE REQURED FOR NSPECTIONS <br /> I hereby certify that I have raper of this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appl ble Ca Ifomia a rq. <br /> Signed - <br /> Title/Company G2LzjF f—,_0 13T/CbNKS7ybA Q,oi 2y 41 1121 oL!L7E:S <br /> Print Name OL,\v E2 Yk1 <br /> Date_ -4/1010 <br /> f(p DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL DDRESS: I / ZS C'.�[. W�L�j J� <br /> WORK PLAN DATED: a'l 2-aI D Cl <br /> APPLICATION ACCEPTIrD BY <br /> DATE IS UED lU AREA <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION BY DATE ([) <br /> DESTRUCTION INSPECTION BY DATE <br /> COM ME NTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# <br /> RECV'D BY DATE PERMITISERVICE# INVOICE <br /> S [ 7 / D SR# <br /> C-57 WC -WAIVER <br /> C 7 LETTER OF AUTHORVATION TO SIGN PER IT ENCROACHMENT DOC <br /> EHD 29-07 18/28/09 <br /> WELL PERMIT APP <br />