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k Q�.!y SAN JOAQUIN COUNTY — r. ENVIRONMENTAL HEALTH DEPARTMENT SITE N 600 East Main Street, Stockton, CA 95202-302 DATION .. P Telephone:(209)468-3454 Fax:(209)468-3433 Web:WWW.S' 1"J 1T IV WELL PERMIT APPLICATION JUL 2 9 i!U1 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 16WONMENT HEALTH Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This aPRtWJTy V 1 `dance with San Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heal h epartment. WellLocation20S m u4e<r JG Cross Street t.►w►+�nit Sk City S6 LTD+ Zi,g5,L ••- Parcel Assessor's 003 Property^ `y--1' q Owner_�.1 ��"" OICi yl Address 304 t� '� Oft, City S�VC�Dt^ Zip SZo�-Phone#j�- 137'807 C-57 Contracto,61kWat Wn LF Address SO?- DnAcc. Clr Cit PAW Cry 1 Lic 03S110 Zip"l- Q� t�_ _ Phone Consultant/Sub Cntr + II�-l. E Addreslft 61C 116%,1x S; City 50 Wl- 5b U Phone t ,jfLS. 2D"II b� GIS Coordinates:X Y Township Range Section WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 1Z DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ❑OVER-BORE DIAMETER ❑WELL# ;,PRESSURE GROUT ❑*OTHER GROUT SPECIFICATIONS flf_" rt ❑EXPLOSIVES DETONATING CARD COMMENTS: t tAW-L -. PCe5SQr�2- Qrook, oYcr•dCtiLI tp Sf 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 TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX,BORING DEPTH ©BOLTED TRAFFIC BOX OR El STOVE PIPE COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT 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 California Laws. ! Signed _ "—� _Title/Company Y S CL14`+ST �is Print Name 5��• W&i Date 1.2I f 10 DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: Fill F enow low WORK PLAN DATED: - APPLICATION ACCEPTED BY _ DATE ISSUED 2.% AREA GROUT INSPECTION BY FINAL INSPECTION BY �iMQQ;.. DATE 1V fi!�6(j DESTRUCTION INSPECTION BY DATE COMM ENTSICOND ITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE 3�`Cl 6v o° o`l!2 5 z �- $ !� S R# C606 I C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT y ENCROACHMENT DOC EHD 29-01 10/28109 WELL PERMIT APP