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oA4�"k• V SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Q � SITE 600 East Main Street, Stockton, CA 95202-3029 MITI SITE Telephone: (209)468-3454 Fax: (209)468-3433 Web:www.sj,�rglehd ATION UNIT IV 44lF OF�S1` WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin Coun)y Development Title,chapter 9-11W5 3 and�e Standards of San Joaquin County Environmental Health Department. Zn 6,,.,6 Sir.,P,�wrOsrs 4101 10' fir> la / Assessor's Well Location,(.2 O 7�', u Y c7 P � ross Stree f�C,_._'D 1 S� City h Zip�/S�[/f� Parcol# Property ,./ ) `/J ` / -2- G�� Owner.C� ] C;-4sTfiG,�T�G� Address 5 /U, Ef o-""Ck a S7'. City Zip s.-,? Phone# 2 C-57 Contractor CtJ�Oc{r.1ar Address (SCJ,I�f�.('��c. �j City k"Q Zip y�LLic* 7-1002 Phone ConsultanVSub Cntr W dSL, nYoJAtidressll3SQ,��'!/ �„�.y-� i� �f�tt� City,fc�h., a6,0/a' Lic# Phone��/ X L c a IHC 40 7`t-a GIS Coordinates:X 37, �? Y- .? ,Township Range Section WORK TO BE PERFORMED: ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ❑OVER-BORE DIAMETER El WELL# PRESSURE GROUT ❑-OTHER GROUT SPECIFICATIDNS ❑ EXPLOSIVES DETONATING CARD COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ❑HOLLOW STEM DIA,OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREWE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAF IC BOX OR ❑STOVE PIPE CON UCTOR AS1NG PROPOSEDI YES.Yist s cf tions in ccmment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACH NT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and all applicable C lifornia Laws. Signed TittelCompany�J Zp� SC , „r C ryi[ r Print Name J Date 5- DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,AD KES-/IS: b OWEN WWI WORK PLAN DATED: APPLICATION ACCEPTED B -tn.,,tc� DATE ISSUED AREA GROUT INSPECTION BY11"4. FINAL INSPECTION BY LGS-(il�litrlGDATE y 24 (J DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE -3 yo C70 Z o g q (,�Q Y t b fo S R# SC1 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 10128/09 WELL PERMIT APP