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JUL 0 �S 2009 j <br /> EN` iRON;VIL7N., <br /> SAN JOAQUIN COUNTY <br /> P E RNI;T,��,,,; <br /> ENVIRONMENTAL HEALTH DEPARTMENT I E 1 <br /> 600 East Main Street, Stockton,CA 95202-3029 MITIGATION I <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s!oov ora/ehd UNIT IV <br /> t WELL PERMIT APPLICATION I <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin Coorty for a permit m construct ander install the work described. This application is made in compaarme with San <br /> Joaquin County Development T@le,chapter 8.1115.3 and the Standards of San Joaquin County Envimnmental Health Depalbnent Assessots <br /> well Looalion lrF,3q 54-L'81! Lon-e,T«-c. Rcky Gs 25PI-5-12oParcel� - -2--tza-oY i <br /> Property ,— Address/601 Cab,illo C+. Cay CSCCG/O,. ZIp�3SS'Phonef <br /> Owner_�;,, �^_ rte( .__._— /� /p <br /> C-STCortractor aX�..,[�A.o� 1���11_.}Addreas Po 130 <br /> 336 ciiy YC ,a "r fc ue: nona7o7-37V�fZaa <br /> ConsulfantlSub CntrATCksocl Address/11-7 qq//--'�Phene <br /> GIS Coordhvtm X .Y ,Townshlp 5 Range�—Section 2-4 <br /> WOi;1(TO BE PERFORMED: <br /> [g'REW WELLlBOR1NG(CPT,GEOPROBE.HYDROPUNCH,HANOAUGER.OTHER-) [j DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SAIL BOWNS - ❑ DIAMETER- <br /> [I <br /> IAMETER❑PRESSURE GROUT i <br /> ❑'OTHER - GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 2/OLLOW STEM DIA OF BOREHOLE t:l ❑MULTIPLE CASINGS❑MULTLL.EVELLWELL CASING DL4:2 <br /> [3EXTRACTION ❑AIR HAMMERDRNEN CAS WG THICKNESS SCL Y'O TYPE OF CAS94M Clr"� <br /> STEEL O C 13 OTHER <br /> ❑VAPOR �11D ROTARY DEPTH OF GROUT SEALq r4 6�TREMIE TYPE TO BE USED 1GERS O HOSE <br /> L3 AIR SPARGE/OZONE ElPUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:L+4s ]No//(NOTE:MAXIMUM <br /> �F�REE-FALL.DEPTH IS 30) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS N/l.l lr C9-� r,'✓`^ <br /> OTHER: ❑OTHER APPROX.BORNG DEPTH / 0��(&BOLTED TRAFFIC BOX OR [3 STOVE PIPE <br /> t COIIDUCTOR e�pNGPROPOSEO (AY65,4r apeFdieaeonahmmmmrteeeti <br /> COMMENtiS: Ir WOCIG n�[n �-r. OnaIv.G41&rr� ri <br /> Jr I12r}�rohr` Ll+ Inw41 r.- N Id 4 aY <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREE AE OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby oer0fy that I have pmpared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regolatlands ppaCobb DO- a Laws. <br /> Signed TIIMJCompany ' ' ZC r 6 o)"L i-f 4 LC f1 <br /> Date <br /> Print Name E �m <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN MIT rV FRE,ADDRESS: <br /> WORK PLAN DATED: / <br /> APPLICATIONACCEPTEDBY!Miff nrosr DATEISSUED AREA '���� <br /> GROUT INSPECTION BY IiVks-..a��^^ FINAL INSPECTION BY l,Q-r.r..nt C-a.s DATE ZZ"/V-2 <br /> DESTRUCTION INSPECTION BY DATE �7�� �� <br /> COMMENTSICONDrDONS: <br /> MPECODES <br /> ONLY: AIDS FAC 0 <br /> FEEDWO AMT REMITTED CHECK# RECV'D 13Y DATE PYo ,ov 6363 0 (� I ` 6, o SR# SITS?- <br /> C-57 m -WAVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WeuPERWTAPP <br /> ElD2P87 111SBT CAEaI <br />