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,PqV I" SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �y Telephone:(209)468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> ED <br /> WELL PERMIT APPLICATION <br /> N ` t010 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> l.Fl0 iQUb`JSbl1EWV ki&&-1$4n Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Jo�1i NONO[T�lp`�"Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> lg3o V:C�w �„ Lt, Assessor's <br /> Well Location R d Cross Street �F ��e��— City L o � � Zip Parcel# <br /> Property Vat ey ; (- <br /> Owner 52­J.cet, Address W(o wts'F Circle City S+oCkfLvi Zip 5ZO(, Phone# <br /> Nb9_ 1-7op <br /> C-57 Contractor Address 3fsoko Dy�l, Cree Df• City S+uc,kFw� Zip 952-15 Lic# 720 `>61/ Phone <br /> tJ'rJvr <br /> Consultant/Sub Cntr AT^-iq C:c Address 170y S4-,e e a- City ES c a l c . Lic# Phone $�,fs - cft Er 9- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ' NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# VF-,,)I -Sy 6-)I - zy 6w I -b ❑PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING J&HOLLOW STEM DIA.OF BOREHOLE li?-" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 2- <br /> 11 yll <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 15 r-�,• y 0 TYPE OF CASING:❑STEEL P'PVC ❑ OTHER <br /> 1 <br /> [VAPOR [Ic MUD ROTARY DEPTH OF GROUT SEAL > TREMIE TYPE TO BE USED PAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:E3 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ✓- Q Q-�- -I- Lr--r v- <br /> ❑OTHER: ❑OTHER. APPROX.BORING DEPTH I 1 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ll$ w,l( lw- i^s>`w//e d i. o sin u/P bre k o I P - <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 applicable California Laws. <br /> Signed < Vk--- oyJ Title/Company Sfa�� �eo I�y f U/o �^c� 7e--o 14 v.,.�r S S <br /> Print Name Jam— a l� Date z /U <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY �� DATE ISSUED S /0//B AREA <br /> GROUT INSPECTION BY �� FINAL INSPECTION BY DATE <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 /> Ogtl V- y�/ o4-,C 10 SR# 5� o <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />