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DIN • SAN JOAQUIN COUNTY • FILE COPY <br /> z• ^� � ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> of ///��� <br /> �.. 600 East Main Street, Stockton, CA 95202-3029USE, �fIATION <br /> Telephone: (209)468-3454 Fax. (209)468-3433 Web:www.sigov.org/eh U V <br /> gLIFo.�a� <br /> WELL PERMIT APPLICATION ApR 2 9 2010 T IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU �[3�PYl'b(OVT f <br /> 44it/g� rlE"LIH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application Is d 49fignpliance with San <br /> Joaquin County Development <br /> Title,chapter 9-1115.3 and�thhee Standards of San Joaquin County Environmental Health Department. <br /> Well Location5�1'lk.J lAl.����YrU�ross Street 1�O�IV�hO�. pQ6 V�, CityJ' Ip Ac Assessor's <br /> Property`t,., _ - 2 �/��` Int r1��� r-,�� �" Parcel# (C12-2 022_ <br /> Owner JI I I`c,>I'/, %.IC r 7h��, 16ddress �0 J�.'tC(,l 4( "5 I t�Q .CityPJ <br /> Zip Phone# <br /> C-57 Contractor VW(J�� C�Q..f 11I1f�Q Address rte' R City l...1 ST <br /> I� /� � AA J �Jn l�\II.I�ryTYd�C� n� c^^ 1 ZipCt_�CJ7 Lic# II�CD99 Phone <br /> ConsultantlSub Cntr AF.CCM Addressl0001 9600(lGv�Ag city '�1,lL Lic# Phone- k-1l-CG"FC0 <br /> GIS Coordinates:X 38.poo ,Y —1:24-5116 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> LW NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 11 DESTRUCTION(CHOOSE TYPE BELOW) <br /> W'SOIL BORING# sV-2i SV- 3 ElOVER-BOREDIAMETER <br /> ElWELL# ❑ PRESSURE GROUT <br /> [OTHER OM.pOt' \Ajek\ GROUT SPECIFICATIONS <br /> /- / o� y� \❑ EXPLOSIVES DETONATING <br /> -/CARD / <br /> COMMENTS: �c W <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING M-T/OLLOW STEM DIA.OF BOREHOLE S t%\ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:Offto <br /> El EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS � �7/1C`Ii TYPE OF CASING:❑STEEL 0 PVC OTHER�`n <br /> 11f VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE V <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:0 Yes LB'No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING T( <br /> HAND AUGER GROUT SPECIFICATIONS <br /> 0 /OTHER: 0 OTHER: APPROX.BORING DEPTH �� M BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specitiootions in comment section) <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, d all appliqable <br /> -- _ California <br /> orniaia Lfaaws.. <br /> Signed 1 , Title/Company Pro <br /> Qfp, / <br /> Print Name UUP—V\", '' V- <br /> Date Q <br /> cam/ DEPARTMENT USE ONLY a��a <br /> SITE MAP IN UNIT IV FILE,ADDRESS: J7D(�/s�pa6 a, � 1)(,rx <br /> WORK PLAN DATED: avrekdZO/G <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 6600""' <br /> GROUT INSPECTION BY 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# INVOICE <br /> ?not k/ ?? la. 6?1 z.L itz9R#tb�j M <br /> C-57 V WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 <br /> WELL PERMIT APP <br />