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SAN JOAQUIN COUNTY �2 ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton , CA 95202-3029 MITIGATION �. Telephone: 209 468-3449 Fax: 209 468-3433 Web: wWW.s' ov.or ehd (� WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S0 9 0 2009 Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appl' de�rl. ppr i ia((cgfryith San Joaquin County DkvOelo. p)'rlent Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Healt PI Iyl IV IFIL' fl Well Location 130 N. Hur ter Sb . Cross Street Cko.v%Rel S} . Ci Sfiact}Ov. Zi o arcel I ZOZ2 Property Owner Ci +!j 0 -� S} OC. 0n Address 411 Al. EI Dolado S}. City St'ocKtotn Zip9S2oZ Phone # 2. 09 ^ 937 - 7sy ) C57 Contractor P ec : Si n, Address 2366 W, Awawt Dr. City S ' ncK }nyv Uc # 3 3 Phone 209 - '45% Qly Tre wa{ ( a, P Consultant/Sub Cntr tolls AddressSS$ Man�gew�er�, S}. � 1300 City$e,n P(nnG<<O Lic # Phone tIIC� `ISS'_ d10 GIS Coordinates: X Y , Township Range Section WORK TO BE PERFORMED: - NEW WELLIBORING (CPT, GEOPROoggE HYDROPUNCH, HAND-AUGER OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) ® SOILBORING# SB ^lA� /� Y0 X30 �0 � El OVER-BORE DIAMETER ® WELL # Med45% W- MLN - 6 < M1a/ El PRESSURE GROUT El *OTHER 1 r GROUT SPECIFICATIONS COMMENTS: rr 11 TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS S ¢� Aa�''{gC A Ai0.graw.S R MONITORING 9 HOLLOW STEM DIA. OF BOREHOLE ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _ ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER ❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE ❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ❑ No. (NOTE: MAXIMUM FREE-FALL DEPTH IS 309) ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE CONDUCTOR CASING PROPOSED (If YES, IlAspeciications in commentsectlon) COMMENTS: NOTE : OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulationssy+/�/n�dd alliica rGalifornia Laws. ! Signed / P � , Tom / Title/Company 51z . ('RcrguCT S�IE� NT \ $' TRERDWELt. &'ReLLU Print Name HleL N41E D . CNE ND214 o 10 Date 21 lSF, G9 DEPARTMENT USE ONLY p SITE MAP IN UNIT IV FILE, ADDRESS: 130 O o 1 *Pi I4 UYL+er S1�LreJ R l A h t O"7" LV V WORK PLAN DATED: ` eGElm bGr�� n�� lo�2 O1D4 I / a APPLICATION ACCEPTED BY V I ,G P i GL f ki r I 'ng:Cl DATE ISSUED J.2 % 111'01'81 AREA SJ7 GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY r 1 DATE COMMENTSICONDITIONS: kyanC2me� L Of S 0 " 9 /ori® inSta ) Iat'O ^ e-(^ », OnrtoYN wells MW-Scrag a n,bu 54 ;YLAono ACCOUNTING ONLY: AID # FAC # PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE 3sol a ' oa 4 34 . 00 092 11:21W091 SR# 0098971 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 2491 11/5/07 (WEB) WELL PERMIT APP