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SAN JOAQUIN -- <br /> �`� � SITE <br /> 2:' ? ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> one: (209)468-3454 Fax: (209)468-3433 Web:www sigov.orq/ehd UNIT IV <br /> d P <br /> 2010 WELL PERMIT APPLICATION - <br /> 0Y 1 9 N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /vl �.�d� <br /> rrnn,,``'',, I HEAL uin Count for permit to construct and/or install the work described. This application is made in compliance wit San <br /> Applicati�tl�VF1 Y p <br /> Joaquin Cou�itE pter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location 1,50\ W.CN-�rArr- l,)- <br /> �' ross Street Z)S_TCb_^Q � City ��7�c5ctl: an Zip `��70��' Parcel# Ido\3�-401LV <br /> Property J #CZw�9 �" <br /> Owner �or<-_� C�....,�n 1 l t� nt, <br /> Address s St .3. C i.A.�er �c,. City �i���e� Zip <br /> 9 SZt1(c Phone 114Z <br /> T (c34 <br /> C-57 Contractor17r;t Address City csv:\\ Zip 015_SLic# Phonet,6j,3 <br /> �t pc, <br /> Consultant/Sub Cntr�r�,,..,Alc,s An�wJAddress 1}t�N ra`.. rcic-� City CsccLdvl Lic# 84 Phone(TT ' ` 71913 <br /> GIS Coordinates:X(n3Z_Ct l 14Z-.ti Y Ztt.3t�15(�.F,S,Township IJ�1 • Range A)14- Section NvE <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) &DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# t;4gVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> [I EXPLOSIVES DETONATING CARD <br /> COMMENTS:�uL c�r:�� a �` of n�.� vet, ���c .c \Z Sc p✓.Ad )l� -�i� bCc <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 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑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 f <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) (� <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,el_ p�icable California Laws. <br /> Signed �D` .a Title/Company I?C,, C- ro A aa-C. j>an��+s' c <br /> Print Name Z r'C Date_ :5/1 1 ao O <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES �(C <br /> WORK PLAN DATED: —�( <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> y <br /> GROUT INSPECTION BY FINAL INS T lY_BY_ _ _ J DA-1 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> 4-57wc <br /> FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> qc-)5. Ci�C. P', # 0 1 <br /> -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29-01 10/28/09 <br /> WELL PERMIT APP <br />