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°r44l... • SAN .JOAQUIN COUNTY • FILE C0PY <br /> z ^` ENVIRONMENTAL HEALTH DEPARTMENT <br /> " 2` SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 o (�f�f'11�I� GATION <br /> q<. Telephone:(209)468-3454 Fax: (209)468-3433 Web:www.s' J�J LI V LS <br /> IT IV <br /> WELL PERMIT APPLICATION APR 2 9 2010 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IS9(' 0i'V14Et�4pTl N,tEA�pL H <br /> wr `SCM <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This axlIit;vl9ade'll�C0lxlpliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> City`� Zi 5qC <br /> Assessor's <br /> �q�ChoO�JWell LocatiorParcel#IOZaPropert UL Croas street Zob \h�I <br /> Owner �� p1UrDaiess PADR�DOZCity51 Zi 15 O Phone#311511-43©.4r0M <br /> C-57ContractorUJWW\1,tQAddressS' nk\OQiQ(lL6 CRYRiO & Zip� Lic# t� Phone <br /> J <br /> Consultant/Sub Cntr rFrnn-X AddresswCity kl_ic# Phoneq(_k -11)400 <br /> GIS Coordinates:X .JD.OQ(� ,Y -17-1. 4111 ,Township Range Section <br /> WO K TO BE PERFORMED: <br /> NEWW 6yLL/BORING(CPT G`EOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) F-1DESTRUCTION(CHOOSE TYPE BELOW) <br /> nOIL BORING# I ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑ PRESSURE GROUT <br /> G?'OTHER to-A^jr yVpi GROUT SPECIFICATIONS <br /> r/ ^`❑_ EXPLOSIVES DETONATING CAR/D�., <br /> COMMENTS: 2:�L r/ A0.4-r .G,` r ✓V�/IL�C�/`LP,� /�J� <br /> TYPE OF WELL �v INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ElMONITORING W HOLLOW STEM DIA.OF BOREHOLE t) fin, c❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA •Z�r71 <br /> 0 EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS O ITEC�-X% TYPE OF CASING:EI STEEL El PVC V OTHER 61 On <br /> ` <br /> [1? APOR 0 MUD ROTARY DEPTH OF GROUT SEAL -f4— TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE V <br /> —` <br /> El AIR SPARGE/OZONE [I PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes LV rvo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') C <br /> ❑SOIL BORING VHAND AUGER GROUT SPECIFICATIONS /— <br /> 0 OTHER: [I OTHER: APPROX.BORING DEPTH lL' -C—'C M11 OLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED h� <br /> COMMENTS: (if YES,list specifications 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,andall Cte California <br /> Signed Illh+,6 f stl-."I) Title/Company <br /> Print Name t`Q.(� � P,�c� Date (JL <br /> DEPARTMENT/USE ONLY 2_'T.&0 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S�Oo/J(�6 LLci/y�G. Q,(ye #3 <br /> WORK PLAN DATED: ZOIO <br /> APPLICATION ACCEPTED BY DATE ISSUED 5'S'10 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> kACCOUNTIG ONLY: AID# FAC# <br /> FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> V V�/ G. tc a4 R#b 8 3 <br /> C-57 44 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 <br /> WELL PERMIT APP <br />