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oP4Kt�• SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> cq ^ i�1>3 (209)468-3454 Fax:(209)468-3433 Web:v W v.sigov.org/ehhc1 7■�■U��N���/I����T�/■I�J�V�■■(� <br /> (IFO r V\\V;! ■ IL FU <br /> ''nn WELL PERMIT APPLICATION <br /> ,;JN 1 5 i4ON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is �" Toi�Lyyty for a permit to construct and/or install the work described. This application is made incompliance with San <br /> Joaquin Count t rW�aWWMo(CCECrrrr 1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> f}�.rt � 'I �r��y Assessor's <br /> Well Location 7/L . Cross Street MA'RU1 �A'� City �fX&rO t/ Zip -lam Parcel#10- 1/ <br /> PropertyII� <br /> Owner TA¢h—E�'r C°n l'• Address Po AUX q6 City /NN F Zip y0 Phone#I •_ <br /> C-57 Contractor G �G• Address 11350 MONIAS PAk p.City Ip g57HZ Lic#-70 S1 phone <br /> ConsultantjSubCntr/sL41A--51n Address2Q000N R1116� City73t6 Ar9OAKLic#�Phone(0)Z3o-/Zd6 <br /> GIS Coordinates:X 6 $oZZ-. ,Y q2-06235 ,Township 'ZAlRange�-•77 Section 2� <br /> WORK TO BE PERFORMED: (q/6!1w-$010 <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> C]SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> `OTHER ZEMJFOZARV 501E GAf ROBS GROUT SPECIFICATIONS <br /> j7 AA`Z BJ TO K FSE'1 Mrs ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: q $O/G �Af FolA3 56-1 -r#"Kyl6f4 5-51'V <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 41A TYPE OF CASING:0 STEEL ❑PVC 0 OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:XYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> (SOIL BORING ❑HANDAUGER GROUT SPECIFICATIONS G13H_01V-r lvy-0�lt <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 5 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSE— (if YES,list spedfi ations In comment section) <br /> COMMENTS: <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,and all applicable California Laws. <br /> Signed "�//��v Title/Company T/I�� tea/ az — NID/Z (y�D/p6/f j <br /> PrintName a ;I/ Date D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> 4 �—j fp Dt C L t 01 .� <br /> WORK PLAN DATED: -s- 11-6 �it) <br /> APPLICATION ACCEPTED BY IADATEIIISSUED -Ls,(1�AREA <br /> GROUT INSPECTION BY n FINAL INSPECTION BY V Iek 919&T !Mk7 <br /> I•&TT'n.Gc- DATE / / 0 <br /> DESTRUCTION INSPECTION BY i n I✓' m t g+"}'YLC�'1 DATE L <br /> COMM ENTSICO N DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3 �oS� 1noo ZyRsy,9 0 b /s" t� SR# oZZ-T <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />