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OCT-27-2009 17:37 ARCADIS BRIGHTON MI 810 229 8837 P.02i06 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �i SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.Qrg/ehd UNIT IV <br /> •,t,Fra: <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applica6an 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 /> d �{ AbSarsot' ct <br /> Wall Location �0 P—Obe-e730 oss Street Q 1��- City ���� Zip -�- 1�paroaE# l [7 <br /> Property Address OO Yta 64& �rrra /�' ` t-R&S' <br /> Owner CT 7�'� �,� � �r5g r1Ge. City � Zip Phone#� <br /> C-5T Contractor _.y o JQL_ Address 3a9a P,��1��� 81�Ldty P��h'� Li #7u�9 2 na <br /> Consultant/SubCntr �C ALL Address lcSScf C'/1j-,09-/0/J City 8rrc�, 1.�-0AJ Lic# PtioneF00--465.0640 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT, EOPROBE YOROPUNCH,HAND-AUGER,OTHER-) F1DESTRUCTION(CHOOSE TYPE BELOW) <br /> L�OIL BORING# OLDS- ! 4 0145 ❑OVER-BORE DIAMETER <br /> ❑WELL# )PRESSURE GROUT <br /> E:)'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECT C T ON <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE rf ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL 0 PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY,W_,_ DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Y" IR No (NOTE:MAXIM M/FREE-FALL DEPTH IS 30') <br /> INSOIL BORING ©HAND AUGER GROUT SPECIFICATIONS C�e/YLP�ri l /&4,,r�G <br /> ❑OTHER: ___•,,,,„__,-_„ ❑OTHER: ., _._ ____ _APPROX.BORING DEPTH _J % ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> p� �CONgu-7 ASI P (11 YES,Biel spwad lcoone in comment emuon) <br /> COMMENT& i2 0j w CCfC I & /A) <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 prepare this app!catlon and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulatloan all a lica//ble�']C <br /> Signed vv TitWCcmpany <br /> Print Name C-LI Q r)eS Date, 1,0 y/a "-1e)q <br /> QEPARrMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z�J Z24( 1nnLo 6.9,%A JO L, <br /> WORK PLAN DATED: to lz-tl o`j <br /> APPLICATION ACCEPTED BY DATE ISSUED.� Z-r�C' i ,AREA_ <br /> GROUT INSPECTION BY FINAL INSPECTION BY r DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE 11111 1 INVOICE MI <br /> z 39,Do \111;0 SR#5 1F5 632— <br /> C-57,-,_ WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> E4029-01 11/5/07(WEB) WELL PERMIT APP <br />