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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' gNI� IT IV <br /> IFO � Ut� <br /> WELL PERMIT APPLICATION <br /> JAN ] 6 2009 <br /> NON-REFUNDABLE MIT EXPIRES 1 YEAR R M DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. T Ns�VI S��iMEALT*pliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental He€� VI(`ES <br /> Cssessor's <br /> Well Location J04o W.6afflaon "1614 Cross Street Gir twbr�a ` City S 6_L%.... Zip 1119 Parcel# 160-.Q <br /> Property <br /> Owner 7- ElwavtSYla, Address Y•o• 6^^ 'lo City allaa�Tr Zip 'TSz21 Phone <br /> C-57 Contractor Creonreoo�Dr�_ Address 9Sb 11ow v •14. City t'Anr41naz_ Lic# 8 11�Phone A&V- 318- SBoO <br /> •2Q,.•. 116 3Y0 ' 5OzS <br /> Consultant/Sub Cntr.gyp Address3m�IckSL�y 54U%OD City RsncJne C.(A Lic# Phone `it`•ter• oN>o <br /> GIs Coordinates:X ,'D QQ _ 'Y_ .✓J,� .Township Range Section <br /> WORK TO BE PERFORMED: <br /> IS NEW WELLIBORING(CPT PR HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> M SOIL BORING# 5111-t. st-z,•a-s se-N. [IOVER-BOREDIAMETER <br /> [IWELL# ❑PRESSURE GROUT <br /> Cl*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Dr..A 4 1. S -T1"' C--Z•--- 4.'A� - y L hor:,A ItI4 e��le aro �.+ 1•— �cwraa�„�• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE 20+ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> O VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> 0 AIR SPARGE/OZONE I!rPUSH POINT(GP OR CPNCLP GROUT SEAL PUMPED:0 Yes [eNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [if SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS pp� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH IO i�l ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED IS Yes.lint epaollka W'h worn axtb ) <br /> COMMENTS: <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 pre red this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a pit a alifamla Laws. <br /> Signed _� Title/Company Will S z'� '54 /G}„-�� <br /> Print Name p GAJ.. IFarvwlwnn Date pp <br /> DEPARTMENT USE <br /> /ONLY Z/• S0 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Ile p �EI✓ (�y� 7`7/ <br /> WORK PLAN DATED: ro / <br /> APPLICATION ACCEPTED BY DATE ISSUED —A 'o AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIO NS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> C-5 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOG <br /> EMD 29-01 1tl&W(WEB) _ <br /> WELL PERMIT APP <br />