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�QUrN SAN JOAQUIN COUNTY <br /> �. <br /> EN ONMENTAL HEALTH DEPARTM T SITE <br /> r 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:W LM— � ��n� NIT IV <br /> WELL PERMIT APPLICATION JAN 1 6 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> EN'dIR CNS"T��(t{ pliancewithsan <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. Thlsl�. . <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental He II �Rq sSssor's <br /> [_+; P1nc�, e City G lb'. \.�n Zip `1s Z19 Parcel# 160-,� 7b-/8 <br /> Well Location 30'10 W 0 n- ri tit tt• Cross Street vebr �Z' 0��� <br /> Property o, $,,, Flu City T) \� �. Tx Zip 'isz'[.\ Phone# <br /> Owner 7- Elev%. _^`• Address P• <br /> C-57 Contractor •RdLic#4BSIUS Phone 4ZS • At—t-- <br /> Address "150 <br /> w &X% tta - 5025 <br /> ConsultanVSub Cntr �/' <br /> Address Sion k1�,- '2'1,5°'\4%00 City Rw1d1 t"�eAP4mUc;# Phone `\tb•961% oY°a <br /> GIS Coordinates:X <br /> Y—•j Z�,JJ3 ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®NEW WELLIBORING(CPT, OPROB HYDROPUNCH,HAND-AUGER,OTHER-) ❑ OVER-BORE DIAMETER <br /> ®SOIL BORING# H6-1 56-Z SB-�•58-H. ❑ PRESSURE GROUT <br /> ❑WELL# GROUT SPECIFICATIONS <br /> ❑"OTHER <br /> 00 1'i.vJ. <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �`_^ 0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:,_ <br /> TYPE OF CASING:D STEEL 0 PVC 0 OTHER <br /> [I EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO 8E USED❑AUGERS❑HOSE <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> ❑AIR SPARGE/OZONE L?TPUSH POINT(GP OR CPT) GROUT SEAL PUMPED:0 Yes LeNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [(SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Cc <br /> APPROX.BORING DEPTH lo+. 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> OTHER: <br /> ❑OTHER: D CONDUCTOR CASING PROPOSED (if YES,list specifications in wmment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all a(/'Pliic a alifornia Laws. <br /> Signed S 1 Title/Company eLx-ice <br /> Date <br /> Print Name paM a- & '"ar yt <br /> DEPARTMENT USE/ONLY h ® Z9 SO <br /> SITE MAP IN UNIT IV FILE,ADDRESS: -�/t/Y'� G(/ E/✓ (Y�v� d��� <br /> O 9 <br /> WORK PLAN DATED: 47 q <br /> DATE ISSUED AREA <br /> APPLICATION ACCEPTED BY <br /> FINAL INSPECTION BY DATE <br /> GROUT INSPECTION BY <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 PERMIT/SERVICE# INVOICE <br /> U6 �`l. / 3 DIS' ME <br /> C-5 WC -WAIVER _C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> FILE COPYL PERMIT APP <br /> EHD 29-01 11/5107(WEB) <br />