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Jan. 12. 20009 3:51PM*ATC GROUP SERVICESI <br /> IiJC. o I <br /> ��J V <br /> JUL 0 3 2009 � <br /> ^ SAN JOAQUIN COUNTY ENT I4RUNu44�4ALTH <br /> ENVIRONMENTAL HEALTH DEPARTMENT P ^n��I� �E� <br /> 600 East Main Street,Stockton, CA 95202-3029 �j <br /> Telephone.,(209)468-3449 Fax.,(209)4M3433 Web;WWW.SigQ,y.oralehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FR M DATE ISSUED <br /> Applicallon is hereby made to Sen Joaquin County for a parmh to consuurd and/or Install the work described. ThiS application Is made In compliance with San <br /> Joaquin County Devoopmem T"me,chaptern�9.,1Q115�3 and the Standards of SonJoaquinCounty Environmental Health Department <br /> AssasWell Location 1 �c.l� - . �`'roas Street Lon.-X 1`e� L- e zip 151.E� Parcel Dra <br /> Property{J -�"" 5 G SS32a Parcel A.. 22 <br /> owner 1\•M p C1 AJLQ,._II Address. 1(01 Ca.hr,)ID C} Cgy L-S Zip�Phone• <br /> C•57Contractnr Rs7.7D 1' •,,LL'A'�dd�. �--O N, L444 $-l. city WO� ' UbA 9wne fl V-12y <br /> ConsuhagllSub Cntr rxWdresSL� Luna.PG�w, u. zokdy Iib I.k0 Pho.2011 ��g- ZI <br /> GIS Coondinatee:X ,Y ,Township J Range�_Section <br /> 1NORK TO BE PERFORMED; <br /> I[,NEW WELLIBORING(CPT, EEypPPROBE, UNCH,HAND-AUGER,OTNER•) ❑DESTRUCTION(CHOOSE TYPE BELOW <br /> OIL BORING# U' 15 (S. ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> L]-OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTIONSPECIFICATIONS <br /> ❑.MONTORING ❑HOLLOW STEM DIA.OF BOREHOLE 7,' ' LI MULTIPLE CASINGS 0 MULTILEVEL WELL CASING DW <br /> E3 EXTRACTION <br /> EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS /k/-4 TYPE OF CASING:D STEEL O PVC E3 OTHER — <br /> ❑VAPOR ❑MUD ROTARY -DEPTH OF GROUT SEAL -�2-V TREMIE TYPE TO SE USF .D AUGERS O HOSE. <br /> E3 AIR SPARGE/O7.ONE LUSH POINT(OP OR CPT)Q GROUT SEAL PUMPED:Ld s,{0�No(NO�T,E:MAXIMUM FREE-FALL DEPTH 1930) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS /tfp�LO�tiae...7- <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH , ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS. 4+ W 6 CON CR I PROPOSPy - J7. <br /> NOT OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 43 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby earthly that I have prepared this appti ' and that the work will be done I accordance with San Joaquin County Crdinancea,Rulas and <br /> Raguladons,and all aBornl9 <br /> Signed l TdWcompany �, I 'S�` �u,�✓1!1 <br /> Print Name +n 11.✓�Q.f` •C- ^� Date I a" _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I S E. Z. <br /> WORK PLAN DATED-. 1. C'Sr <br /> APPLICATION ACCEPTED BY (A(� DATE ISSUED—3t�AREA <br /> GROUT INSPECTION BY 1AN, AA" FINAL INSPECTION BY t _Ar _ DATE7�D07 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICO N DITIONS: <br /> ACCOUNTING ONLY: AID# PAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECVO BY DATE PERMIT/SERVICE i INVOICE <br /> 35-06 *'Coqc& 1 0157-M( ,61cl 18R# 577 S <br /> C-57 / WC WAIVER -Cbl LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOG <br /> F*nsso, 11rs 7( ) - wells Mrr APP <br />