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SAN JOAQUIN COUNTY 'ao <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 09) 468-3449 Fax. (209) 68-3433 Web: wwwsiooy.orG/ehd MITIGATION <br />*,br'0XF#R49:UNIT IV <br />NOV 13 2009 WELL PERMIT APPLICATION <br />,! t3AIrREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />�N,�`{pI�R��UNI�9ENT HE6u;,q <br />Application is e[)eVe �t MID t County for a permit to Construct and/or install the work described. This application is made in compliance with San <br />Joaquin County i%e��l ap er 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />ST Assessor's <br />Well Location \303 — Cross Street `-\G.N�4 City rcSCte�gN Zip S��' Parcel#X21-zpyz) <br />Property <br />Owner Address q( -k% 1Sc City yz'q \cr+ Zip9CI3Zo Phone # <br />C-57 contractor �iSCy -t\-`- Address 3150 TOkNSVF � City NyoiaoA 04—Y FC # 6'33865 Phone�7—x-68-9'&00 <br />Consukant Sub Cntr Address city cvaw m UC#�, 4 Phone <br />GIS Coordinates: X Y <br />, Township Range Section <br />WORK TO BE PERFORMED: <br />PE CODES <br />❑ NEW WELLBORING (CPT, OPROB , HYDROPUNCH, <br />HAND -AUGER, OTHER') ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />ja§OIL BORING# <br />❑ OVER -BORE DIAMETER <br />LJWELL # <br />JR7PRESSURE GROUT <br />❑ -OTHER <br />GROUT SPECIFICATIONS <br />COMMENTS: <br />y3L{too <br />1 1-6135 <br />fAk <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE f' ❑ MULTIPLE CASINGS[] MULTILEVEL WELL CASING DIA: _ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS b} t- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 VAPOR [I MUD ROTARY <br />DEPTH OF GROAT SEAL C Z 1 tTREMIE TYPE TO BE USEDT] AUGERS)&HOSE �7 <br />s/a�aaa� <br />0 AIR SPARGE/OZONE APUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPED: 0 Yes III (NOTE: MAXIMUM FREE) -FALL DEPTH IS 30') i a <br />SOIL BORING [I HAND AUGER <br />GROUT SPECIFICATIONS I) E/ --TT- C EMEA) I M <br />0 OTHER: ❑ OTHER: <br />1 <br />APPROX. BORING DEPTH �� / —7-1 0 BOLTED TRAFFIC BOX OR ❑ STOVF <br />CONDUCTOR CASING PROPOSED (If YES, list spadsraSms M Mmnenl setlbn) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS eat <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 1 accordance with San Joaquin County Ordinances, Rules and <br />Regulatt s, and all Ilcable California Laws. <br />Signer \�� <br />Title/Company •\ \->�NC�f\i\L �lv� 3�RV\C'�S \N� <br />Date \\\N'g <br />Print Name <br />USE ONLY <br />r <br />p <br />SITE MAP IN UNIT VC FILE, ADDRESS: 130'aj i l <br />�D��EPARTMENT <br />�Si- • N u \i } 3 2009 <br />WORK PLAN DATED: fi x.. b Ft" <br />b <br />APPLICATION ACCEPTED BY (lbnMGGt^ <br />DATE ISSUED It O /M_ <br />/DDATTE' <br />GROUT INSPECTION BY I/�t�M c.�-� <br />143-/—f37 <br />FINAL INSPECTION BY t_AN>,A ,- C o„—� Oq <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMMENTS/CONDITIONS: eA <br />0 1 S <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PER WITISERVICE # <br />INVOICE <br />ZgoS <br />y3L{too <br />1 1-6135 <br />fAk <br />1 11 1 IfiO I <br />I SR#SS K <br />657 WC -WAIVER D57LETTEHUHAUIHUKILAIiCNIVOIVNYCKMII v ENCROACHMENT v <br />ENB teOt 11/Ypr WEB) <br />WELL PERMIT APP <br />