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SAN JOAQUIN COUNTY <br /> EQIRONMENTAL HEALTH DE'PAR NUCI�}�/ <br /> SITE <br /> 600 East Main Street, Stockton, CA 9520 ' Ei TION <br /> - 1 2-3029 qp ITIGATION <br /> Telephone: (209)468-3454 Fax:(209) 468'3433 Web:www.sigov.0 q/e <br /> h� 2010 UNIT IV <br /> WELL PERMIT APPLICATION <br /> r;ElILT� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ''CS <br /> a <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 /> 2�AM Zip�Z� Assessor's <br /> Well Location L4 P'J2 ta S4,Cross Street E , C�C.Lrph _S� City Parcel# J!ZZ,3,/�Z <br /> Property <br /> Owner_IQSS Address 420 2 City Zip , Phone 9-2427-Z,94 <br /> 1s <br /> C-67 Contractor U)00jl,.i�,rj qAddress P,0 1 13(2A-/ 1_1 3 city R 1,10 V,I I f'a� ZIP Lic# Phone <br /> ConsultanVSubL11ntrJ&6�eor-cA'ena(,Address 0 City AaD�o -_ O_ic Phone <br /> 1, GaNJf <br /> GIS Coordinates:X 2t�3a ,Y_ <br /> 4�/, �7,�_��S Township Range Section <br /> WORK TO BE PERFORMED: <br /> [:1 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# I <br /> OVER-BORE DIAMETER <br /> ❑WELL# 0C>;�RESSURE GROUT <br /> ❑'OTHER <br /> GROUT SPECIFICATIONS <br /> IvLal: <br /> F1 EXPLOSIVES DETONATING CARD <br /> azi M W-1 nA LkF-Z-_VV%W-s:, M uJ-TA MU) <br /> COMMENTS: I . I I <br /> M W-If,#NMI rA W_9 M CA)_f -F?-_4- z 0 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> XMONITORING Cl HOLLOW STEM DIA.OF BOREHOLE CI MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS <br /> TYPE OF CASING:El STEEL D PVC El OTHER <br /> El VAPOR 71 MUD ROTARY DEPTH OF GROUT SEAL <br /> TREMIE TYPE TO BE USED 0 AUGERS El HOSE <br /> XAIR SPARGE/OZONE I-]PUSH POINT(GP OR CPT)— GROUT SEAL PUMPED:[I Yes ❑No (NO I tE;MAXIMUM FREE-FALL DEPTH IS 30') <br /> El SOIL BORING El HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: F]OTHER: APPROX.BORING DEPTH El BOLT TRAFFIC BOX OR 0 STOVEPIPE <br /> CONDUCTOR INGq4OS D (i ES <br /> ,;E,�p�lrif2ifions in comm t1aw" <br /> dL-- <br /> e_ <br /> COMMENTS. (QEal KE I �7 <br /> C U <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 /> Regulations,and all applicable Cffornia Laws. <br /> Signed Title/Company <br /> Print Name V id te Date 0 <br /> DEPARTMENT USE ONLY <br /> FILE <br /> SITE MAP IN UNIT IV FILE, DDRESS: CO P y <br /> WORK PLAN DATED: v <br /> APPLICATION ACCEPTED BY DATE ISSUED LfhfbO AREA <br /> GROUT INSPECTION BY 1,&.1b4►AAA nt— 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 PERMITISERVICE# INVOICE <br /> 611C SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGNIPERMIT <br /> ENCROACHMENT DOG <br /> EHD 29-01 10128109 WELL PERMITAPP <br />