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� , � • SAN JOAQUIN COUNTY • <br /> ?. ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 p <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.s' ov.or / <br /> WELL PERMIT APPLICATION SEP 0 3 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application iPERMjT�SERV1 h San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ; ���� µ^rE Assessor's <br /> Well Location _,2vi>( 5�( Cross Street ___—_—_----_ _—_ City � Q �-�Zip ___--- Parcel#44_'OJVY <br /> Property <br /> Owner__R.P• Ic5z)n — — Address P a_goy,-a`4Scity 401t- —_ Zip 95-D34 _Phone# qG4-agsq <br /> e-s-f <br /> C-57 Contractor taber'Cs�UIHZPvSAddress2M W_ 1`61 Vim° • CityW.S1V--� Lic#44A'10Phone`16" 0 <br /> Consultant/Sub Cntr__--_—___-- Address—___----_-----__ City -----_-- Lic#_---_Phone__—_--_— <br /> GIS Coordinates:X—___-----_— ,Y —___-----_--,Township _—_--- Range__----__ Section _---__ <br /> WORK TO BE PERFORMED: <br /> 1K NEW WELL/BORING(CPT,GEOPROBE�NPH,HAND-AUGER,OTHER.) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> Z[SOIL BORING# !o CO _� _ ❑OVER-BORE DIAMETER----_-----_ <br /> 91 WELL# _— _ . t��l U7.2US ❑PRESSURE GROUT <br /> ---------- <br /> ❑*OTHER ------ --------_-- GROUT SPECIFICATIONS --_--_—__ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CON TRUCTION SPECIFICATIONS <br /> C9 MONITORING HOLLOW STVAPPROX. <br /> IA. F BOREHOLE _ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:� <br /> ❑EXTRACTION ❑AIR HAMMEASINaG THICKNES$,��TYPE OF CASING:❑STEEL V PVC ❑ OTHER <br /> ❑VAPOR )$t MUD ROTAREPTH�F GROUT SEAL S6 TREMIE TYPE TO BE USED-7J AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINTROUT SEXL PUMPED:%Yes No(NOTE FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGEROUT SPECIFICATIONS❑OTHER: ❑OTHER: _ BORING DEPTHC�,n�w _ El BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED t ;S1­-d(,v,'tV-!Aj'(if YES,list specifications in comment section) <br /> COMMENTS:--------\----- <br /> I <br /> OMMENTS:_—___--- ---- --- <br /> NOTE: OFFS;tT E BO NGS 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 California Laws. r ' 1 <br /> Signed ��,/� �� ---_Title/Company�r0 I� (�tU i�IS <br /> Print Name —Date-- ,/ //l ------ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: --_------_ --_ _— — ------------ <br /> WORK PLAN DATED:------------------- — — ---------------------- <br /> APPLICATION ACCEPTED BY _-----_ DATE ISSUED _ _— AREA <br /> GROUT INSPECTION BY _----- --- FINAL INSPECTION BY_--------_ _ DATE ---__ <br /> v DESTRUCTION INSPECTION BY_--------_-- ----- DATE_----------__ <br /> COMMENTS/CONDITIONS: ---__ _----�------ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# ECV'D BY ATE PERMIT/SERVICE# INVOICE <br /> SR# <br /> C-57_---WC _------WAIVER _-----C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _-- ACHMENT DOC_---_ <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />