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oPgwrv..c SAN JOAQUIN COUNTY <br /> �.• �� •.o <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> N: v <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ephone:(209)468-3454 Fax:(209)468-3433 Web:www.s'gov.org/ehd UNIT IV <br /> a`.;.. .••� 3 0 2009 <br /> WELL PERMIT APPLICATION <br /> ENPVIRUU�MAR NT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereIT made f,Ogf 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 San Joaquin County Environmental Health Department. <br /> Assessor's �D3� <br /> Well Location (0 7L-j e. V,L}� Rd Cross Street N. C-I v FS F A,e• City Lod% Zip q r `�°2 Parcel# <br /> Property <br /> Owner ✓+ De ' '�q r S Address 101q &., v;Cfa-1 R d. City Lo d Zip 9S 2 Y o Phone# <br /> C-57 Contractor Address %Ftib Dvat­ C rte 4_ Dr. City 5Zip q 5 21 S Lic# '7 z°ifo'f Phone <br /> Consultant/Sub Cntr Vro v"J -Le" Address 1'7)t4 Ma-^ 5+. City GS C a I w• Lic# Phone 8'J B-- e/tf$8' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> PNEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# MW l y ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Dd MONITORING HOLLOW STEM DIA.OF BOREHOLE _' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z U <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Scl1. N V TYPE OF CASING:❑STEEL P PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL H (D f TREMIE TYPE TO BE USED AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:PYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS /V2 r4- L'✓0')t <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH LD S BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 applicable California Laws. <br /> Signed , '\� �1 Title/Company 57+o•f F <br /> Print Name J n Date 11 11 o cl <br /> �j DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �l/�� C Vi do--L <br /> � l �t ' <br /> WORK PLAN DATED: lI (� i—C L)P,/A/v`CG <br /> APPLICATION ACCEPTED BY DATE ISSUED D AREA <br /> GROUT INSPECTION BY �J_Km " y\ FINAL INSPECTION BY DATE/ D, <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: Qihi�C Wim/ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> D r <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> EHD 29-01 10/28109 lc6 WELL PERMIT APP <br /> /i� 5 36 3 �`t �6� <br />