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PQutN � � C (OPY SAN JOAQUIN COUNTY a ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 SITE P- NEDone:(209)468-3454 Fax.(209)468-3433 Web:wwW.sigov.orq/ehd UNIT IV MAY 1 9 [010 WELL PERMIT APPLICATION N „/3 .NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED til/ �--nn''��{{p(� T HEALIn o-�30q Applicati0tilGLli uin County for a permit to construct and/or install the work described. This application is made in compliance wit San Joaquin Cou�iY pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's Well Location i5p` (),C1%a ec l,�co�Cross Street 5.�ces, c, City ��,c�1.�ae� Zip 95aof� Parcel# I(o3� ol(v Property Owner.��<�� 1" _ Com , _ Address 15cii w, C•i.4,aer W City S is Zip 95U(o Phone#C2v�q�$-91t�Z �43ao)(03 C-57 Contractor ��.� `l� c,, Address 3150`Sti'r,,.,a,.� 31," city cs "l� Zip 015�� &345 Lic# � � honet}5�S Consultant/Sub Cntr�t ._�r�letn A 6.j Address I}l�-�c,w City �Scc l b vl Li# 8 1 4 Phone Czci�)8323 5)9n- GIS t 9n-GIS Coordinates:X(n3Zct 144.it _Y ,Township cNVN Range Section NIA WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION(CHOOSE TYPE BELOW) [I SOIL BORING# VER-BORE DIAMETER ❑WELL# ❑PRESSURE GROUT ❑*OTHER GROUT SPECIFICATIONS ^� ❑EXPLOSIVES DETONATING CARD COMMENTS: c,,,,\ a -t,.,X- n,-,e 1,z\l. Sc" p elebac 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 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) COMMENTS: W NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS �S 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and o�d Regulations,and icable California Laws. 1 Signed ( .' Title/Company PC, Gra.,,.A Zero c. Print Name Ls;c L. Pr:,e Date 5 ))q- 1 acsio / DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRES : WORK PLAN DATED: APPLICATION ACCEPTED BY DATE I -ED AREA ,,,, GROUT INSPECTION BY FINAL INSPECTION BY DATE616 DESTRUCTION INSPECTION BY DATE_ COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODEP FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE#4DOC CSC ! # !� -57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHME EHD 29-01 10/28/09 WELL PERMIT APP