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l <br /> <��` ' ':c� • SAN JOAQUIN COUNTY • ��'�� l�' <br /> i <br /> ENVIRONMENTAL HEALTH DEPARTMENT T <br /> 600 East Main Street, Stockton, CA 95202-3029MIT TION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siclov.oro/ehd NI IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 00/ 15y/ <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 /> Assessor's <br /> Well Location z°LKI M c H e!Y4 Aot Cross Street JI-4c'> Roc.8 City Ec ca 10,1 Zip 9 S3 Z O Parcel# <br /> Property <br /> Owner LiomvAakiS Address 'ta451 AAtMfn!y AvA— City ESLollrnn Zip `S?10 Phone# <br /> C-57 Contractor V k w Address 39ob P.,L- C,,ee L b". City 5+oc k-fV%n Lic# T z Loy Phone 46 k' '77 O 0 <br /> (reo-^a Z o <br /> Consultant/Sub Cntr Asa i j s Address t 7i y City lw. Lic# Phone if 3 S--c1 t frf- <br /> GIS 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 /> SOIL BORING# SB 1 - l ❑OVER-BORE DIAMETER <br /> UT <br /> F-1*OTHER E]GROUT S ECPRESSURE FOCATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Z" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS MA TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 2 V TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes h No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> I!,-SOIL BORING [:]HAND AUGER GROUT SPECIFICATIONS Ate-,+ Ce wW�� (r eo-�+- <br /> `❑OTHER: ❑OTHER: APPROX.BORING DEPTH _L0 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (I 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,and all applicable California Laws. . <br /> Signed ` f� Title/Company Sf-W Veo I o y S U✓b ^1 Z e--v A,-IIS S' <br /> Print Name J v e- �/ 1/�G.'�- Date I + q/0-1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNITFILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE 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 PERMIT/SERVICE# INVOICE <br /> allbJ 1 ' !t o sR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SMW�T ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) RECEIVED WELL PERMIT APP <br /> NOV - 6 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />