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- San Joaquin County <br /> Environmental Health Departct {��(��n/J� (�j SITE <br /> - - 600 E. Main street, Stockton, CA 95202-3 l�� limos VV l`�ITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: www.$)gov.or e <br /> it 0 2010 UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DA72wrIMN,, <br /> Ea■ !J! <br /> T HEAUV- <br /> Joaquin Cou hereby�made to San Joaquin County for a permit to carmhuct and/or Install are work fltlltfon bWmetle In <br /> �Y 7F,t�m Title,C Ptw 91115.3 and the rds of San a^�ience with San <br /> Qom- o (s ..ti Slanda Josqun CDunry Erwironnent I Department. <br /> G, Ty rrr 'r r: (rT a Assessors <br /> WELL Location 2ri99 we rrrr c,o„stre`r`r r e.r city Sha kt� zlP °LSZab ParceY I63 3yo ny <br /> PROPeg7v " " <br /> owner �:7^Xo�fft��tr�y�y 2Sad!L/..-T PKI city Stec nP St6 PnanasYA'f�937-87Y0 <br /> C-57Contractor /Cuc�,,oma„{,5247, �acucco G�tv�cdy ,r9 s3cs 9l7Phor 7_S-S,j -ly90 <br /> Consultant/Sub Cnb Cel A�re,GFr'hlf it ld ess /g Q Frc..l. Wase Phon t —o Sf g <br /> GIS Coordinates,X 63Z32-D Y Z 161 A g I.q 3 TewneNpJ N Range_Seaion_4 6 <br /> WORK TO BE P915rClik.. Sc a <br /> D NEW WELL JUNG (CP GEOPROBE DROPUNCH.HAND-AUGER.OTHER-) D DESTRUCTION choose <br /> D SOIL BORING* ( lYpe ) <br /> 0 WELL s D PRESSURE . DIAMETER <br /> D PRESSURE GROUT <br /> .$'other of^h of, nft, A V«. a u,yl; oc r s-1 /aear,-m 5GROUT S/PIECIFICATIONS <br /> COMMENTS' aT I p+d -310 -F �r hal.•.- err✓..�Sr+Ze <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA OF BOREHOLE-Z D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL LS-2►' L/�1r TREMIE TYPE TO BE USED: DANGERS D HOSE <br /> D AIR SPARGEI OZONE .,PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yea D No (NOTE: MA)UMUMFREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS J)4A'C- pe Sri�l lAwnMns� <br /> D OTHER: D OTHER APPROX. BORING DEPTH I C•Se Lh D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> r CONDUCTOR CASING PROPOSED (H YES,list spedffcaaons in comment section) <br /> COMMENTS: 6 <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 In accordance with San Joaquin <br /> County Ordinances,Rules and Re ulat ons,and all applicable California State Laws. <br /> Signed x - Tioe/Company 0C, <br /> Print Nam _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: SrA� T L <br /> WORK PLAN DATED: • <br /> Application Accepted BV Date Issued S Area <br /> Grout Inspection BY Date Final Irmpe w Hy Date <br /> Destruction Inspection+by Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AIDN TFACXPE CODESFEE INFO AMOUNT REMITTED CHECK{ Y DATE #(a, <br /> PERMR!SERVICE REOUEaTf INVOICE <br /> i1D h�l•o' 1241r.11 SR#S <br /> C-57_Z WC -WAIVER_ C-57 Letter of Authorization to sign permitEncroachment doc_ <br /> 111-11329-02-001.1, <br /> 6122104 <br />