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t <br /> og".''. -c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> `, 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 4 P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.s'gov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of SanJoaquinCounty Environmental Health Department. <br /> Well Location� -I ly SG Cross Street CMIIgY� 4' J� Ci }},,_ tom, p Assessor's <br /> City S�CJG i Gri-. Zip 1,102 Parcel# 39010C!?, <br /> Property {{++ 1 <br /> Owner G -u GC STV C� tIL Address 30�{nl• j T�eruta City��}Sc 0� Zippq S�?AZ Phone# �jg?-$<39 <br /> C-57 Contractor CA S Address 3(03 2 OM4L Cir Citq� &L 19� a--Zip Y 7. Lic# 9(ID Phorne ' <br /> Consultant/Sub Cntr _j_'5_ Address f 5 City 'z1Soe^_ Lic# Phone%-9? -. z <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ®DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# RrOVER-BORE DIAMETER }Z" <br /> ❑WELL# 2U PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS l�to%,t C:EN4 <br /> 11--11 <br /> El EXPLOSIVES DETONATING CARD I <br /> COMMENTS:t�] -S Mw-� W-7 IAw tAW-IOtA Mlle ' \nj-[ W- + Q If(L pd6 OYlx-dr111 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS EJ HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSE=D (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all app' ble Cal' a Laws. I <br /> Signed Title/Company fmY C tt , S fleua<<5�� 471 S <br /> Print Name • J W�. J J Date -7. OV O <br /> DEPARTMENT USE ONLY FILE <br /> C <br /> SITE MAP IN UNIT IV FILE,ADDRESS:{{,!C� C-ZAA, 'c, S43e124 <br /> WORK PLAN DATED: ..7- 2 ---_-,- <br /> APPLICATION ACCEPTED BY A C,-_w DATE ISSUED '-$ AREA <br /> GROUT INSPECTION BY _[/��na�[�i� _ FINAL INSPECTION BY DATE O ze 1p <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 35-oz 460.00 0y [2!�_Z 1_12-W[1_0 SR# 60(, '5- <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2M1 10126/09 WELL PERMIT APP <br />