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o,gM.ly. a SAN JOAQUIN COUNT ( ���� <br /> > •.,� <br /> ENVIRONMENTAL HEALTH DEP SITE <br /> 600 East Main Street, Stockton, CA 95202-�8 9 U 2010 MITIGATION <br /> Telephone:(209)468-3454 Fax:(209)468-3433 Web:wiO+N. V.or /ehd UNIT IV <br /> a WELL PERMIT APPLICAIFI owiw WAM <br /> RWISERVICES <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 D Yet opment Title,chapter 9-1115.3 and the Standard of San Jgaquin Counrnvimnmental Health Department. Assessor's <br /> F^� 17 n')'ti Icc<T�cnJ cn �•^ •L r'J'Fclt 57a�y�tz+n Zip�S�Qb Parcel# <br /> Well Location Z Cross Street ¢w Y $5" Z ••e-. �.-au.6 <br /> Property City St^SGT^y ZIP IdsaO- Phone 'TT, T �' <br /> Owner Address �.r�(.C�EI'rf t - <br /> Cact Tr Scn Jaml�.n � � 69 9$pQ <br /> C-57 Contractor Address X99 She/'s /pct City •c It �^ Zip�SZ Lie !.S" P o e <br /> n e^t4 1 <br /> Consultant/Sub Cntr C 06Ja r FFFa./f/._ Address�ft�F�a^Ir I✓!r'/�/•Ste pty f G} Lic At Phone Z- Iq a��t3� <br /> GIS Coordinates:X <br /> �3) e 0L ,Y 'Z(61262�77 •Township i ./ Range Section 7-#25 <br /> f@2. aatGf� <br /> WORK TO BEP�F�R�Q ED: <br /> [:]NEW WELLL$-QBINGiCPT, EOPROB , YDROPUNCH,HAND-AUGER,OTHER') -BORE DIAMETER(CHOOSE TYPE BELOW) <br /> 0 SOIL BORING# 0 PRESSURE GROUT <br /> TER <br /> OVER <br /> ❑WELL# ,�/�I ,^ GROUT SPECIFICATIONS <br /> OTHER t t 1' • ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS:- �T �n—yp� 1 r+ t �ti A M be IOw s'^/-r k'e <br /> - "" - vet vHA,i r l •Ttif e�/��l•�:— .��� � W I l�" _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL 0 PVC 0 OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEALIF Tw7r TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE *USH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS P..rlel(A. -e'.'I"'k <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH __. [IBOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list s wftafions in c mnt 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 /1 Title/Company G, 0 <br /> Print Name [JIC 4 _. Date f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ZSOD %fj ayW1 ,j,�rjuv t- ... <br /> WORK PLAN DATED: O 6 <br /> APPLICATION ACCEPTED BY DATE ISSUED jTd L J AREA <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/SE4# INVOICE <br /> -a(i> SR#SC-57� WC -WAIVER C57 LETTER OF AU I HORI TION TO SIGN PERMIT�-� ENCR <br /> EHD 29-01 10/28/09 WEL <br />