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.; SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> �C v IUJ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> / Telep one:(209)46&3454 Fax:(209)46&3433 Web:www.siaoV.org/ehd UNIT IV <br /> B 0 S 2010 WELL PERMIT APPLICATION <br /> ENVIRONMENT H�EAI -R FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PfflWApplication Is a to San J�quln 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 Sen Joaquin County Environmental Health Department. <br /> Well location H�A.-03 IM ; f�Street 0l t� A ,e. city A^V'_. a ca Zip a S 3!o t, Parcel#iAssessos <br /> Property / <br /> OWner Ss•` JOfAg„ CV. V'� Address 1610 iia Z p� 4" C S fvc kl�+ ''16 <br /> nY zip 9 f Z v S Phone# tr-;d u e <br /> C-57 Contractor Y W D.;11; I.,c.Address3$0b DvLI� Ce4tk p-. City SfvcI<h­j Zip9S'zfS_ Llc# 11_010q <br /> p --7Yvv <br /> Conutant8ub Crttr ro+ .Address I /° hS . one <br /> AvwI4��j City s C hone <br /> Ir hS— <br /> Ills Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORINo(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [-DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS ../!d4 ci <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: AA✓ .SLS V rr�t <br /> TYPE OF WELL INSTALLATION TYPE CONNIRUCIM SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASINO DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN 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 SPARGFJOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: INO <br /> CONDUCTOR CASPROPOSED IM YES,FM spedflontlom In cmwr*m"orlon) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 4e WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have Prepared this application and OW the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Reyulattons,and all applicable California Lon. <br /> Signedd0 TKWCompany S+4Ff tr,ol•4r3 f`/ Ir-.•tea/ 7efm A-r.!y( S <br /> Print Name n 2 tg N t° Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: InA <br /> WORK PLAN DATED: 1 i 'Z-1 1 1 0 <br /> APPLICATION ACCEPTED BY DATE ISSUED 2 1 l AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY�.{ ...s�_ DATE���(a <br /> COMMENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES �INFOAMT REMITTED CHECK* RECVD BY DATE PERMITISERVICE# INVOICE <br /> Z9oZ $/ov'00 o19�ry5 z ►� ►� SR# S01370 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 <br /> WELL PERMIT APP <br />