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SAN JOAQUIN COUNTY <br /> xl } � ENVIRONMENTAL HEALTH DEPARTMENT ITfi <br /> ,n 600 East Main Street,Stockton, CA 95202-3029 ATNI <br /> TION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sinov.orglehd (V <br /> .l�gj'r�ytx <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM QATE ISSUEQ <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 /> z o J s we S �'o a d Cit pAssessor's <br /> Well Location NSf M�t{e�✓-1 Aub.cross Street y $S cac Irn.t Zi ° 2 v Parcel* <br /> Property <br /> Owner U,;Cq OonvA-a-S Address 16451 Mtflsn/ Cky EA_Lc4Iyt^e Zip 9'ST20 Phone# <br /> C-87 Cgntractor V w O r:11;,, fi e,Address 306 D wctt UM L D✓. City S+9r-1- Lic# "710 9 Phone <br /> (rro. a 7P�ro <br /> ConsultantlSubCntr 615tw(:I } Addresstolx .� s�. City ScaOv«. Lic# Phone x°35'-4/>Pyl?- <br /> 013 Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> PNEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> RLSOiL BORING# 49 1 - (® ❑OVER-BORE DIAMETER <br /> yEH # ❑PRESSURE.GROUT <br /> ❑-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: 4 <br /> TYPE OF WELL INSTALLATION TYPE r4ONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA._ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS )VA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER 3I <br /> / 1 <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 'Z D TREMIETYPE TO BE USED❑AUGERS❑HOSE !) <br /> ❑AIR SPARGE/OZONE 19PUSH POINT(GP OR CPT)„GROUT SEAL PUMPED:❑Yes 03 No(NOTE:MAXIMUM FREE-FALL DEPTH IS 90) <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Ns w{ C4-' M+- (r"a <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH Z o r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED pt YO,Inst opOWIc om In corrnm t sem,) <br /> COMMENTS: <br /> NOTE: OFFSITE BORING$ 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 app cable California Laws. <br /> Signed cr-C_ 04 'rdwCompany Si--W <br /> Print Name J o e- v v �._ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNITFILE,ADDRESS: <br /> WORK PLAN DATED- <br /> APPLICATION ACCEPTED BYDATE ISSUED 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 PERMITISERVICE# INVOICE ! <br /> C-57 WC _-WAIVER C57 LETTER OF AUTHORIZATION TO S ENCROACHMENT DOC <br /> EHD29-M 1115107WES) RECEIVED WMPERMIT APP <br /> NOV - 6 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />