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ENVIRSAN JOAQUIN COUNTY • <br /> ONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> J J} 7F 60 0 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �J hone: 209 468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �rFaR UNIT IV <br /> j U N 2 9 2010 WELL PERMIT APPLICATION <br /> t �" il7 'I!Ttt�T � ii. <br /> ENNUI}MJ<It K`1�,, II IHl A,L THNOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ApplicatioFiisI ALT/nYadl?IfblSSdnn5 to <br /> lication is <br /> Joaquin County Development Title,chapter 91115 3 and the Standards of San Joaquin llCou ty Envthe work ironmental Healthribed. This pDepartment.ade in compliance with San <br /> Well Location DSa rC• I`'1LlYi OSc� �/t� ��P �q}y City `J�o GIC�-aw Zi 5205- Assessor's <br /> 1 P Cross Street t' LTl tuA �nrmin n p � Paroel#3� <br /> Property 1 c+�x" <br /> 0161 <br /> Owner Itilnnllel lilCV3,Jr, Address 190�}E. (�Iq,,-',ppsq Q�. city 5+7�Ir_k+on Zip 9SZOS Phone# 4- 73- e7 <br /> C-57 Contractor Address 4S N CX'q 1I Cv1 City RL'Y7O Zip 93-1 VLicX 7? Phone <br /> Consultant/SubCntr Address City Lic# Phone( VRO-4311 <br /> GIS Coordinates:X 3-1.939-7 ,Y -1 , Z�2g ,Township 5'FOC_k�O 1ti RangeSection <br /> WQRK TO BE PERFORMED: <br /> M NEW,yWELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> Lti SOILBORING# 2 boring"; l5 i-o 25 �'ee�rV <br /> ❑WELL# �`7 PeP [I OVER-BORE DIAMETER <br /> ❑'OTHER ❑ PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> f/ ,/ �1 f.n ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS L7in f.0. /w-La <br /> TYPE OF WELLIN TAI LATION TYPE CONSTRUCTION SPECIFICATIONS, <br /> El MONITORING HOLLOW STEM DIA,OF BOREHOLE W <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESSTYPE OF CASING:0 STEEL ❑PVC 0 OTHER46 6 n _ <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 15 r 2-93 TREMIE TYPE TO BE USED❑AUGERS 0 HOSE <br /> ❑/AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes [ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0/SOIL BORING DHANDAUGER GROUT SPECIFICATIONS <br /> ❑OTHER: 0 OTHER: APPROX.BORING DEPTH 5/ S 1 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> (if YES,list s ecRcations in comment radion <br /> COMMENTS: CONDUCTOR CASING PROPOSED P ) <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 /> Regulation¢,,�N II applicable California Laws. <br /> Signed /X Title/Company ei�a1v12P Ana �Y' D ��G. <br /> Print Name P Date June 2 'Zo17) <br /> �.S DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Sy. f2� I Seo C.4_-"f6+-_ 95.,qS r7�Q 9 5 J-6 <br /> WORK PLAN DATED: Y?- /D /�/(_ (>EO 01--1 ✓oq '�— t7 L <br /> APPLICATION ACCEPTS BY DATE IIIS/SU�EI _7, AREA <br /> GROUT INSPECTION BY1�1=/�^�o-� FINAL INSPECTION BY DATE 6 lb <br /> DESTRUCTION INSPECTION BY DATE <br /> COM MENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 9.oS SR# �oYoa <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/0945-X7 647-L$3q <br /> / ' u���-. I'Le, 71,411 <br />