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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT p SITE <br /> { 600 East Main Street, Stockton , CA 95202-3029 �`' c �ON <br /> \ Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.or%a e <br /> WELL PERMIT APPLICATION " '' 0 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEIT IkUII�j�w1rIW(L��NTHEALTH <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicable � <br /> n Is IR with San <br /> Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> Well Location MO /V. Hvn+e. r S}. Cross Street G/�0•rsv%e ( S} . city S+04 Kbo to zip 9S zo z- Parcel # 1311 ToZZ <br /> Property 11 L� I <br /> Owner ( It' y 0-F SIOCK4} 0% Address 4Zf A[ S1 Po(adv Sk• Cfty S+OCK41118 Zip 20Z Phone # 2409ft93-) - 7S 41 <br /> C57 Contractor FiSc Dr . IU III Address3150 AbIrtAsov. %4L City "�Ae &Ville Lic # 693"d6f' Phone 7o7 - 76%- 4800 <br /> 7 ftiii,AtyS IIaw 1 ITITOO <br /> Consultant/Sub Cntr 20110 AddresaSS /Vtt� w'I'u orvtf/L Sf0 Citysun i^mrV ace Lic # Phone 41S' - 9s5 - 9ay0 <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> ® NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER") ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> ® WELL # MW � 7sl MN„/ % * A ❑ PRESSURE GROUT <br /> ❑ "OTHER GROUT SPECIFICATIONS <br /> COMMENTS: ii 11 11 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS rjQ;e Q+Iadmhal eag(O*AS <br /> EF MONITORING ❑ HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br /> ❑ EXTRACTION ❑ AIR HAM MER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL O 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 <br /> CONDUCTOR CASING PROPOSED (OYES, tAspecifications in commentwaon) <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 /> Regulation It al( a p 'c (e California Laws. <br /> Signed IYL C Title/Company <br /> 1J� • ���£C� XtEt�l�� 5j ( 0DWE4- �L' �-btJ--° <br /> Print Name AICt*FLI) • CJf5P1DOQatO Date ^�<� SEP 0 <br /> -7 <br /> DEPARTMENT USE ONLY � L <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 138 D r 4 14UYL-+ G Y• elY L B <br /> WORK PLAN DATED: 1 ,MQrek o? Z/ . 200 <br /> APPLICATION ACCEPTED BY V I e +A f i f4 Ale Ca rin edLt DATE ISSUED 1241 - 0 '7 AREA 111Y ? <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY 1 1 (� ,DATE I, .t , • / �v .I � ,I <br /> COMMENTS/CONDITIONS: � nsia ) 1a+- ; mA riY rmonf -6r1.20, WQIIS MVJW 5 ,inn W - P al <br /> ACCOUNTING ONLY: AID # FAC # - <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> 3So3 345toa If 94600 ` 434400 70921 K/n7 j � • 11 - U9 SR# 05 b9 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2&m 1115/07 (WEB) WELLPERMITAPP <br />