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O 'NA L <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUL 3 4 2009 SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 G <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www ff NT HE <br /> PERMIT/SERVI I D <br /> _ WELL PERMIT APPLICATION OW <br /> .r NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WDY. 7 <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 /> 6633 Pacific Avenue Benjamin Holt Drive Stockton 95207 Assessor's 09741048 <br /> Well Location Cross Street � City Trp Parcel <br /> # <br /> Property Lincoln Center Trust PO Box 7611 San Francisco 94120 (510)237-1782 <br /> Owner Address City Zip Phone# <br /> C-57 Contractor Cascade Drilling, Inc Address 3632 Omec Circle City Rancho Cordova UC# 932633 Phone (916)638-1169 <br /> Consultant/Sub Cntr Holguin Fahan 6 Assodates Address 5627 Stroneridge Drive,Suite 300 City Pleasanton Lic#N/A Phone (805)641-4091 <br /> GIS Coordinates:X O i Y 121. 2I Township T2N ` Range R6E Section S21 <br /> WORK TO BE PERFORMED: / <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) �S ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# /,,, VER-BORE DIAMETER a^tor 2^wells,lo^fa a^w Is <br /> [I WELL# /"/ LrJ PRESSURE GROUT /rC <br /> ❑ <br /> *OTHER GROUT SPECIFICATIONS <br /> COMMENTS:_ Iw <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPBCIFIGATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA'.- <br /> 0 <br /> IA:❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> f 1 COND OR CASINGS PROPOSED Y list specificat i,oonvnerd�eclim <br /> COMMENTS: Vi <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, all applicable Califomia Laws. <br /> Signed Title/Company ocep. MAY• o. <br /> Print <br /> 1►�I, h <br /> Print Name h l o Date,. Cr 1 / �O ' ��_ <br /> ��jj�� DEPARTMENT USE ONLY Z9• s�' <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ko41ejye4, ��� • V.S <br /> WORK PLAN DATED: Q p <br /> APPLICATION ACCEPTED BY DATE ISSU • .a --AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE O �9 <br /> DESTRUCTION INSPECTION BY DATE 11 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE of INVOICE <br /> 2.41O VOID O 30.0 SR# <br /> C-57 OF WC Aor -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT OMA4= ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHO 29-01 115W(WEB) <br />