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W. SAN JOAQUIN COUNTY <br /> _ ENVIkONMENTAL HEALTH DEPARTMEN I" SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> I one: (209) 468-3449 Fax: (209) 468-3433 Web:www.sjgov.org/ehd <br /> �.;.. .. .,;: UNIT IV <br /> JAN 0 7 Z010 WELL PERMIT APPLICATION <br /> ENVIRON[, ENT NEAMWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE COPY <br /> PERMIT/'SERVIGE <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 /> 31$1 5. ST-A-M 2oore 9% WEST h7F W-64t. Assessor's <br /> Well Location Cross Street E. tt4%P)4FeRD W- City 4ZMCY-TaK Zip g$2/S Parcel# 100" 1 Z <br /> Property 1.E t_10E 31671 16 SR*•441 tAb ZC!"?- <br /> Owner 5CHtA1DKE TR.VSh-r Address FV­ftKTAC-sE- ;6,1;. City ST&C-y-- PI Zip �`'hone# 94&- <br /> C-57 ContractorCpFOCcaN ChaSMAddress CP4 71 1 GLISA ST City LIVJE.RI.10911l# /�SOPhone <br /> Consultant/Sub Cntr 15AMtE Address City Lic# Phone <br /> GIS Coordinates:X 4, T2s I Y z41995-73 ,Township 1 µ Range -7 E-� Section 1-7 <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING(CPT, EOPROBE, YDROPUNCH,HAND-AUGER,OTHER') ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS. <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 ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑ HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT GP R CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS WEJsT C L�J"1re(fir <br /> ❑OTHER: ❑OTHER APPROX.BORING DEPTH 4 Fr ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED if YES,list specifications in comment 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,an II applicable California Laws. L7 E�N <br /> Signed �/ �y Title/Company-51?- PAa:!k-r• 5C/E"TISI' C X73 <br /> Print Name 4214R-15 41!�7 10"M L/ Date Z010 <br /> DEPARTMENT USE ONLY <br /> "� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3/ 6-/ S . S+ate- l�o td� 99 Vv• - <br /> V <br /> WORK PLAN DATED: �Pe-c-ek-w6gr- 30, 2009 ACCEPTED BY V r DATE ISSUED AREA <br /> Vic.+orI0,Ma rtrlcyc�cu�reJ z-a-/0-fry- yV y7 ir.,j-H 1o`b.t9 .ZB29S.St,Rt. 99 a, wage <br /> GROUT INSPECTION BY YI n yr nrP t INAL INS ECTION BY V C,�nt1a rn@C`Qr'�i t DATEZ-2'/D P�97 <br /> DESTRUCTION INSPECTION BY DATE I <br /> COMMENTS/CONDITIONS: Ac�yzin aiq-m� Df -1V L b t) r�n G11 C 4D 4 `j�eat 77 sa <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 2905 99.06) 99. 00 06 7078 1-11-ID SR#coos i29 H-701 f <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />