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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> a�. ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 —,(r(�'-�r� f!,1. TION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.sigo,V:¢Il1,d _'J I( <br /> ,1 <br /> WELL PERMIT APPLICATION C,IAP 2 7 2009 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISS .,�� <br /> khF,DIIYi� , `PJ r I'_�LT <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app(i �jr ad4:jIi >Aance with San <br /> Joaquin County Development Title,,,,``chh'a r 9-111 3 and thgg Standards of San Joaquin County Environmental Health Department. —0&0-08, <br /> Z24 1 5./f 1 A'w� Assessor's <br /> Well Location_ Cross Street Gr4h1 L/',e Ed City Trkcy Zip Parcel# 0q" n0'O'? <br /> Property / t. <br /> Owner Mgc4ajo rNt�i��i T61st Address 6rw,� Ghe ed City Trq(,y Zip 453�� Phone# <br /> C-57 Contractor %A!Aj Address 9S0 htor)l Rd City Mnrhhe Lic# ISS-/65' Phone yZS- .3 I3-n� <br /> Consultan Sub Cntr l -Pr q,Address "of) N/lj,r S� �7Lc � City En�orwi d le Lic# Phone 9l0-970-33 <br /> 1 <br /> �� f ' <br /> GIS Coordinates:X •17f 0 Y IZ4''535 Township Range Section <br /> WOR ERFORMED: <br /> EW WE ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-)48110W-34" ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 0K <br /> 164,11 ❑OVER-BORE DIAMETER <br /> E.�1NELL# M W-I 4-i.,roujMW- vd ❑PRESSURE GROUT <br /> OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [MONITORING HOLLOW STEM DIA.OF BOREHOLE ID ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:2�y <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SC(7 r TYPE OF CASING:❑STEEL X PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL I� f o�_TREMIE TYPE TO BE USED tZAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ;fNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Poi�latitd k held" GeAlaltf ES COk¢ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3`� rl� ❑BOLTED TRAFFIC BOX OR -STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N o (if YES,list specifications 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 Title/Company '-a> ��isf/Co�rer�oSU- 2nvcrs £ Asjooaler <br /> Print Name r Date <br /> �i DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: _,/(/i �'�'� ✓ �G� <br /> WORK PLAN DATED: lZ oe6 <br /> APPLICATION ACCEPTED BY DA AREA D eICI <br /> 07�� <br /> GROUT INSPECTION BY q g FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> 9•Dly 8� � 3 � aj pwb 53 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN E IT RBACI-IAAEAIQT DOC <br /> �j <br /> EHD 29-01 11/5/07(WA <br /> EB) LL APP <br />