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• y • FILE COPY <br /> 'Ak SAN JOAQUIN COUNTY <br /> = ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �/ OR <br /> a P I ne:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.orcI/ehd UNIT IV <br /> MAR 1 7 2009 WELL PERMIT APPLICATION ' <br /> ENVIRONMENT HEALTOREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2-col <br /> FIT/SERVIC <br /> Application is herePby me a 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 /> 11 !t� Assessor's <br /> Well Location JOY E.Gni t L;, KZ. Cross Street W. h.jr'fL. O f-, city Zip 45-17 Parcel# 7S0-1)0-08 <br /> Property _✓ <br /> Owner p(, + E Address 3401 (-P" City (A zip 9K_ S0�Phone#9lS)41 -Q1$ <br /> C-57 Contractor Address 550 P,9-kol,,] City V i Lie#-I jol 79Phone Ol <br /> ConsultanUSubCntr Pvlsa <br /> aa Address -1111f)-. W,'46,A 14Jj CI'Cy �lulrrl+Ge..4�(�I_ic# Phon 4i'- 7 3 <br /> GIS Coordinates:X y��.� 4 O Y — hj - 41 S ,Township �1Z11 Sb�.+I Range S� /-� <br /> 5rt Section - <br /> ORK TO BE PERFORMED: I"- b1W%O R:,4MA/'S��dVI <br /> NEW WELUBORING(CPT,GEOPROBE HYDROPUN AND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> yKA SOIL BORING#, 1 Z �_S-Z ��L) ❑OVER-BORE DIAMETER _ <br /> LJ WELL# —� ❑PRESSURE GROUT _ <br /> *OTHER - 2 i At- - - / .S4 <br /> 6 )A3-S65)Aa-S66I OUT SPECIFICATIONS <br /> COMMENTS:�,o-EL' E 2,t i S S0l'�Gyj <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 1 I\ <br /> P„MONITORIN ❑HOLLOW STEM DIA.OF BOREHOLE L\t ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 111 <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS '-' TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> PKVAPOR0) ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT GP OR <br /> CPT) GROUT SEAL PUMPED:❑Yes -No'�(^NOTIE-:JM,AX,IIMUM FREE-FALL DEPTH IS 30') <br /> )SOIL BORING CL) (HAND AUGER I J�GROUT SPECIFICATIONS �' (zrk - b�-lb'11 6 IqL f cy <br /> s � 1 <br /> OTHER:(I OTHER: Ire. l�APPROX.BORING DEPTH r, ( BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> p CO DUCTO CASING PROPOSED RY S,li spacifica9wsin wmme lsecuon) <br /> lI ,L F <br /> COMMENTS: SC,t. r'CC-)'4f_41ia JOf�.rIl[ti,{f 4I YSG �..�-L!.<r -S'D �t TSC crsanr,�r� LLr{r� <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 /> Regulatio`Jnd all ap icableC I rola L ws. <br /> L <br /> Signed l Title/Company <br /> Print Name _��(hv.Q"I `til n.(i� Date <br /> - <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 9�b ZQ G' `E- -�--�. <br /> WORK PLAN DATED: �0 / <br /> APPLICATION ACCEPTED BY AREA �J q <br /> GROUT INSPECTION BY - FINAL INSPECTION DATE <br /> DESTRUCTION INSPECTION BY DATE ��+! <br /> COM M E N TS/C ON DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> o / 4#I• ! � 3-/ -09 #6 6eD <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ar ENCROACHMENT DOC <br /> EHD 29-01 11/5NFILE capY <br /> 7IWEB) WELL PERMIT APP <br />