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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> W y\ ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �q= Telephone:(209)468-3449 Fax.(209)468-3433 Web:www.sigoy.orglehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> ( NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (/Application is hereby made to San Joaquin County for a peril 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. ,I° <br /> L1 z U ? � (SE n n I�I� A e q5-3 Assessor's I <br /> Well Loco'6on J _ Cross Street CKIn�2Ll Av City �--Arup Zip 30 Parcel# L. <br /> Property I�_ 2,q <br /> Owner Ci f4 O�1 L046012 Address 390 Toin, Ce4re fir. City L-o•�IArur ZipjL�2 Phone# <br /> '- <br /> C-57 Contractor < w Dolllna Address 38ob DuCl4Cr�2}2k 17r`. City S'IUCLG{�rn Lic#320gDy 1�Phone 2U9-�fl-�PDU <br /> Consultant/Sub Cntr EQ&tF0 Address�0 /-I <br /> Iij. LJJI/Ab wja4 ft)�ity JP?l_ Lic#tqtA-_Phone 0L(-'7,c0 <br /> GIS Coordinates:X 3 u I Z- .Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELU13ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) - (ZOESTRUCTION(CHOOSE TYP�@ ELOW) - <br /> ❑SOIL BORING# - OVER-BORE DIAMETER /IS ;n,1- <br /> [I <br /> nah❑WELL# PRESSURE GROUT <br /> ❑•OTHEIEIR GROUT SPECIFICATIONS Q'r CS(�1}n�Poc. <br /> COMMENTS: P�eTrglh0k0- I0004e&0- C6 (LOA(uo )tiro - Ptn'met MN°s a.rr.CIw 1 L ik iA0Q4r1z RwUCI362 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> -OTHER: CZomP. 'f ❑OTHER: APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTORCASMGPROPOSEO (i(YES,Psi speaicafions In commentsecion) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d II applicab alifornia Laws. p <br /> Signe tl //J� /' l(•• Tille/Company PC '2'Ci Mange- / L-`f�L EG <br /> Print Name I\IcharL 6(An A.,Ilz Date O <br /> q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z(l Z E 4�Gcae �7� <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DA AREA .� <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE 7.2--09 <br /> DESTRUCTION INSPECTION BY DATE ��• <br /> COMME NTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# `n FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK#�C44RECV'DBY DATE PERMITISERVICE# INVOICE <br /> W D. 3 L 6 R# <br /> C-57 t nrsmWweal WAIVER C57 LETTER OF AUTT TO SIGN PERMIT ENCROACHMENT DOC <br /> FILE COP*R76W <br />