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tulN. <br /> aPQ"" qo SAN .JOAQUIN COUNTY <br /> ARONMENTAL HEALTH DEPARTONT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 ( [ vOg rIXATION <br /> :,, j Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.s' C Ib IT JIV <br /> WELL PERMIT APPLICATION OCT 8 2010 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE U�Dpp,l '``jj ) i lt-A_Tiq <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applic�aiib�igh%val&liance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health (Department. <br /> Well Location 2 11 [%, I'r r-'^^0�i S�;Cross Street , �-n01d'P,n �A{f A�,P.City S� C.k-}pin Zip 5>.OS Pssescel#rsfy3—u 0-57 <br /> Property tA�� 'y.` <br /> Owner �� CY4e (1G � �X Address PO,?V)< City 1_t{7�t`-8 Zip 9S5- phone# 'Z01-4W%Szy <br /> C-57 Contractor \SCS Address 31 Ro,,4 City 1`4kdy'tk Zip 15S'17 Lic# (,-d3W 7 Phone <br /> P (079 I of <br /> Consultant/Sub Cntr Lf e'. Address 135 S, 5(:� I�.ve�Sv+l c� City �IIkIG-.�2 Lic Phone 20 9-g?Tir;k <br /> GIS Coordinates:X '!X),ZSZ'?N ,y 37,9(o7 SI.7 ,Township ( III Range _ Section LY3 14 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT G OPRQBE,HYL%0PUNQH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# .�Dt.Q LSI— L3i'sN� �'� E ❑OVER-BORE DIAMETER <br /> WELL#❑'OTHERUT <br /> S: h I� GIAA f t)to rX- I - I Cop ROUTSPECIFICATIONS <br /> [I PRESSURE O <br /> COMMENTS: ( lY• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLEn <br /> �_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL ,-�D_55 TREMIE TYPE TO BE USED❑AUGERS X HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSO1L BORING ❑HAND AUGER GROUT SPECIFICATIONS Ntr,+ cq,—QY' `I <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3U-5SI ❑BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED 77-0-- (d YES,list sp aimtions 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,an all ap lic'able California Laws. <br /> Signed - �J�----� y Title/Company FG -7 S� Le-'O-\-` t C��-- <br /> Print Name . eC k, 1-at✓ Q Date v f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7,-911 TU kAO,A-f . <br /> WORK PLAN DATED: 10 115 11V <br /> APPLICATION ACCEPTED BY fA�-1MnGl�r� DATE ISSUED 1011qllo AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE L0 <br /> 2R IG <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> LCCODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> (Olt q1t 0 1 SR# 6(Z�;9 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />