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SAN JOAQUIN COUNTY <br /> �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> D <br /> SITE <br /> C11 �� I 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �ephone: (209) 468-3449 Fax: (209) 468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> J441 0 7 2010 WELL PERMIT APPLICATION <br /> al�1� o r t r�t NEFALTI-1 FILE COPY <br /> VR�Wv1 J��`i/�r. NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. 174` <br /> 2829 S. 5'��Ro� <br /> " T� 99 U`'EST 'FRoN'f�6� 2D Assessor's <br /> Well Location rVt( �nd, Cross Street LO5M15 1112.Cn,471D City 5T11--C1C1-bNZip 95SParcel# 110 ^ 1CN <br /> Property TET dDW 1777 5 .H&Ralio <br /> Owner MDPER.T7 E.S� LLC Address � 6M Cnop City DENVER Zip SZt I I)Phone#�Kag-$$B3 <br /> C-57 Contractor 112-11',46 73Address 4A,71 ST. City LI VER.#-1db c#7/4ea"7DPhone "6*-371—G7-00 <br /> Consultant/Sub Cntr '644-4 F— Address City Lic# Phone <br /> GIS Coordinates:X 42:,576 LT I Y Z.a Township Range 7 E Section 1-7 <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT(GEOPROB HYDROPUNCH,HAND-AUGER.OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 3 ❑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 )WIPUSH POIN (GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS NEAT C'EP-IE7,47- <br /> 0 <br /> ,47 -❑OTHER: ❑OTHER: APPROX BORING DEPTH ZjS) FT ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED ((f 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,and II applicable Calif rn• Laws. <br /> Signed Title/Company 5,112, <br /> Print Name allJ21S e-5/U/ M44 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 29 29 S. S+c —]in u+e 9q lnJ. Fro nbl qe, 7V . <br /> WORK PLAN DATED: leaerm6 P.,, 30_ .200f <br /> APPLICATION ACCEPTED BY/ �-I G+0 r I Q tACC�rI✓rt e-s/ DATE ISSUED I-J I �,pU AREA 1-4191 <br /> GROUT INSPECTION BY V 1�G r r I av e r jg:!v� FINAL INSPECTION BY V j(iT d (I G' Me6k-}fXr, DATE2--2-1 D <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: 1hreG t>or <br /> O7 +ul en+ti -beef bs� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> i9vS <br /> "g, q. Qr 89.00 01, '70*7 8 1-/1 - /0 SR# 00S9126 R-70� <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 />