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v 001413 ..� SAN JOAQUIN COUNTY H E, �> x.� ENVIRONMENTAL HEALTH DEPARTMENT SITE j 600 East Main Street, Stockton, CA 95202-3029 MAY 22 20010ITIGATION q. Telephone:(209)468-3449 Fax:(209)468-3433 Web:wyuw.sjgpv.org/ehd ENVIFiONMENV I IT IV WELL PERMIT APPLICATION PERMIT'/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San SOS Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 2Z 115041 ^^�� 33H 64 f4an $f Assessor's Well Location Cross Street �6t�f �I?I � City o Zip 5 36{o Parcel# ` �- i Property S n W Q D K o CA TRv T� F1L 0 Qo S� U >yv S n e te,3 p 00 •fila S o o� Owner +`�+�--�-�` Address a�— i��b- 4o Cit M6\ Zi Phone' — C-57 Contractor Vtt.) Drll�;,�, Address R0.5W q')d City l.o�t Zip GSZYI Lie# -7Z-090q Phone � Zo4-3�t•�[w, Consultant/Sub Cntr GHQ Address 2.pQG C-1 City '�Seui Ilc Lie# Phone 916'6731462 GIS Coordinates:X Y Township Range Section I WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ]DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ®OVER-BORE DIAMETER ❑WELL# ❑PRESSURE GROUT ❑*OTHER GROUT SPECIFICATIONS fvr�iF,d tfh COMMENTS: t�--S+r-,, Iv iWr•''+ WeMIS TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING ❑HOLLOW STEM OIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA.:_ ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL I]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 301) ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and all astNicable C�Laws. Signed - Title/Company S(tiff 5c-ic-iii l Print Name _� C r•,rn 5kr....'1-f 4-e Date �t DEPARTME(�NT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 3 `t n n7 1t" e+ 1 i_O O YN WORK PLAN DATED: h&AV APPLICATION ACCEPTED BY a 1- f r 1G CA Y��L DATE ISSUED S 1 130 0 _AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICONDITIONS:'De-S•} e+1 j,. , u MIA] -3 i� `S�—�s -1, S, -L 177_'1' ACCOUNTING ONLY, AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE 3S0 2 GO.Ov 4• Va -1. 302- 53 L6L 167/30/68 SR#oD54s97 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 11/5/07 WELL PERMIT APP