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SAN JOAQUIN COUNTY <br /> HEALTH DEPARTMENT <br /> E�VFDDENVIRONMENTAL SITE <br /> y: <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> q •. P Telephone: (209)468-3454 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �fFOR `EB 0 8 2010 <br /> {� <br /> WELL PERMIT APPLICATION <br /> ENVIRONMENT HEAgUN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERMIT/SERVICE <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. <br /> Well Location H,9H✓u 4q �ientt �d ll Assessors <br /> y Cy Cross Street O A^Q . City N ^T e-« Zip 9 S3(o b Parcel# <br /> Property <br /> Owner SQ^ Jvaq,,.- Cv„ -4l Address lSlO H- -Lei City Zip 9S-2u5- Phone# 3ou0 <br /> 44p9--7 uv <br /> C-57 Contractor v Dr;t l; h,.Address 3'F0 io p..e-1- 2 G. Dr. City Sfv c k h-i Zip 7 S'7(5- Lic# I LO C9y { Phone <br /> -i4� <br /> Consultant/Sub Cntr—A.-c4 11 S s zrr.Address S4. City FS c u 1--1 Lic# Phone S-3 P- - 7 J1S-- <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) -DESTRUCTION(CHOOSE TYPE BELOW) <br /> [__1 SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT 1— <br /> El <br /> ❑*OTHER GROUT SPECIFICATIONS -�f- <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: ce"t, Tom. . puP <br /> i <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 ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if 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 /> 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 all applicable California Laws. <br /> Signed o) � `V <br /> _ '/ x Title/Company A-� <br /> Print Name ��y VIr. Date <br /> DEPARTMENT USE ONLY FILE Vftr' <br /> SITE MAP IN UNIT IV FILE,ADDRESS: " <br /> WORK PLAN DATED: 12 1 I 1 <br /> APPLICATION ACCEPTED BY DATE ISSUED 2. 1 l I AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE -2- <br /> COMM ENTS/CONDITIONS:COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> ZgoZ �o,do ol��g5 <br /> 41110 10 SR# S13zo <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />