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SAN JOAQUIN COUNTY OCT 0 9 2009 <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> V. ' > 600 East Main Street, Stockton, CA 952o2€ RONMENTHEALTMITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:wwv ?1ffdifVICES 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 permit 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. <br /> Assessor's <br /> Well Location WVLn�_4Ih Cross Street c:.laxic Druz_•_�_ City Zip _ —_ Parcel#.— <br /> Property <br /> Owner 14(+Ljej1- Address =1 it 1.:� � "Is'Jx, NX. cityw1c>Is.,'— Zip%3S- Phone# 2�`I.gUIX;u1�i�i <br /> C-57 Contractor Cc•St4A` Address •ii3'L 7M%t 'i-„ls_____ City 1LGWl,0 C, IAALic# 33 Phone ”)N,�,k.it �i <br /> ConsultanUSub Cntr Ag CA!D-m..S Address --iN4N 0i^n DnSti>c 17a City _��1Sy+� Lic# r Phone `4i�•`(`�S•?D?i C-vr .I j <br /> GIS Coordinates:X Y Township Range Section <br /> WQRK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# _ ❑PRESSURE GROUT <br /> El-OTHER GROUT SPECIFICATIONS _ <br /> i <br /> COMMENTS: MW-b <br /> -j <br /> TYPE <br /> — <br /> Ta� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> RMONITORING -HOLLOW STEM DIA.OF BOREHOLE L15 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:._2__. <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS —TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED❑AUGERS INHOSE0r{,,. <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) _—GROUT SEAL PUMPED:)$J�Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> ❑SOIL BORING C3 HAND AUGER,_ GROUT SPECIFICATIONS S Ta i�.lon�k <br /> 7— <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ,.w-b— �-i LD A BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> CONDUCTOR CASING PROPOSED_ (it YES,list specifications in comment section) - <br /> COMMENTS: 1Air+'�p ___��✓i 11 ��� "�S(9' n� to.Ci cru+ i c: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed �E �• Title/Company— {S� <br /> Print Name ` ,-6* Y-cta Date t,�i i 1011 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ILE-0" <br /> WORK PLAN DATED: 7,671 , <br /> APPLICATION ACCEPTED BY " " ����--- _--- DATE ISSUED 1 C 3 OC+I AREA <br /> __ <br /> GROUT INSPECTION BY �/L�wWL \„ FINAL INSPECTION BY �1�iV1 �(/� DATE t� !3 O <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# _ <br /> PE CODES FEE INFO AMT REMITTED CHECK!,# C RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR# ,S$_SSZ <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 I V5!07(WEB) WELL PERMIT APP <br />