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• �:; .�� SAN JOAQUIN COUNTY ` ED . <br /> ENVIRONMENTAL HEALTH DEPARTMENT P R 2 91N SITE <br /> • 600 East Main Street, Stockton, CA 95202-3029 <br /> •. Telephone:(209)468-3454 Fax.(209)468-3433 Web:www.sicGv�aaalaa8lT HEALTIGATION <br /> Fly WELL PERMIT APPLICATION <br /> P EP,,P�'i f1SEPMICEUNIT N <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 San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Pro Location I`SDI 4J.Ci7c V .Cross Street S. Frocr�0 uP-Q.-o. City 5 QC fon Zip 95201, Parcel#_1(03 -37o/6' <br /> Property � � <br /> Owner- Fir P nok Cam 12 {��. Address 15 r51 bU•Olnov y W 1 City 5+p 0 k bn Zip 0(o Phone#(2o9)9 Off-91 q,7 <br /> C-57 ContractorDr; 'ew Address 5&0lo -Du CL(a rd P DK't yt,City S+r>01 c.4-ogn Zip 95 2 is Uc# ��l 'hone <br /> nsultan ub Cntr�Qun(f 74 ry Addre= I'71 2L&A aj 4, .p City E6Ca-(,,A- Lic#E41±1 Phone(A03)839-91188 <br /> GIS Coordinates:X 3 �� �... ,Y Township t jJ4 Range T—Section N/A <br /> WORK TO BE PERFORMED: <br /> E3 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND AUGER,OTHER*) M DESTRUCTION(CHOOSE TYPE BELOWI <br /> SOIL BORING# OVER-BORE DIAMETER - ' <br /> WELL# PRESSURE GROUT M \&,V 2.&Avjgk4 <br /> "OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: wej(5; a-h 2 '-finrn�f-�- fAnd �5l'yePn�d �rm,� In 3D�v�E <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING D HOLLOW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_ <br /> 13 EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:(3STEEL Owe 0 OTHER <br /> D VAPOR 13 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS E3HOSE <br /> 13AIR SPARGE/OZONE D PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:O Yes E3No(NOTE:MAXIMUM FREE-FALL DEPTH IS 301 <br /> D SOIL BORING t)HAND AUGER GROUT SPECIFICATIONS <br /> O OTHER: O OTHER: APPROX.BORING DEPTH. O BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> COMMENTS: CONDUCTORCASW PROPOSED (IfYES, apkMlo�tloruInoomnwMaoYon) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certifyhave prepared this application and that the work will be done I accordance with San Joaquin County Ordinances.Rules and <br /> Regulations and Il ap ble California Laws. <br /> Signed C Tide/Company P,,(1, ('9 ea A o d 7Q r o .Ana r./a,;s r �r�(' <br /> _. <br /> Print Name Ey 1 c- L. ` r I ce- Date_cT R/10 <br /> EPA EN U ONLY 3� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Y7 ZO Z4!D r V <br /> APPLICATION ACCEPTED BYyw�� DATE ISSUED CO'l 0 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 PERMITISERVICE# INVOICE <br /> JSC-57 WC WAIVnnER C57 <br /> lh L�R OUTHORIZATION TO SIGN PERMIT ENCROACHMENT D <br /> EHD 29-01 1112&!09 OC <br /> ' ' G" S/7/ l 0 WELL PERMIT APP <br />