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A4`'I" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION aq P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sogov.org/ehd UNIT IV <<FoaN• WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Well Location t 6777 1,'OWtgN Assessors �R�.Cross Street —QUlSF Af/F_ City t,/s—YE/Ko.� Zip Parcel# i 9g-!Yo-O V Property Owner Address s�i'fPLoT' _— Address IC777_ (/04_4ef.VD f2D. — City L.jTi9fiPc)P Zip A'—_Phone#.-Ak C-57 Contractor'3444 LON4YG=A,Q Address !333 W. q Sf CityVALANO i e4 Zip!2 75i Lic# 64Y4VC Phone Consultant/Sub Cntr C�4 _—_ Address 1`Z/{�4_Q6_CV/A/ rA"tJY sAy"City f1iCKfbT/ -- Lic#—__—_Phon '2oq 4$3-GgI GIS Coordinates:X Y Township _ Range—__ Section — WORK TO BE PERFORMED: ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION(CHOOSE TYPE BELOW) El SOIL BORING# __ ElOVER-BOREDIAMETER WELL# _—f��il_ El /-'z G LUS��I =� -1 PRESSURE GROUT ® *OTHER —_---------—------------- GROUT SPECIFICATIONS___—__ _---------------------- ❑EXPLOSIVES DETONATING CARD COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ©MONITORING `�� ❑HOLLOW STEM DIA.OF BOREHOLE _ ❑MULTIPLE CASINGS[__1 MULTI-LEVEL WELL CASING DIA:2 _ ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL I,KPVC ❑ OTHER ❑VAPOR ❑MUD ROTARY_ DEPTH OF GROUT SEAL lfsf135 TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)__- GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS ❑OTHER: ❑OTHER: UNI APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR H STOVE PIPE ---- s t-- CONDUCTOR CASING PPOPOSED ___......... _ _ (if YES,!!M spe^'f+ca1;^ .;in,.o-iment sect; ^1 COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,andallapplicable California_ Laws. Signed _`sem► r _ _ _—Title/Company A-.E0oW—K-E --- Print Name s�oRC,eT F,elED _—Date 22 DEPART ENT USE ONLY SITE MAP IN UNIT IV FILE, DDRE S: �� _.� �"� WORK PLAN DATED:_) _�3 -- ---- -------------------------------------- 7 ------------ APPLICATION ACCEPTED BY _ — _..... ___ .... DATE ISSUED ) _�_b AREAl t _ GROUT INSPECTION BYFINAL INSPECTION BY _— DATE DESTRUCTION INSPECTION BY _ _ _ DATE --------- ------------------ ---- ------- COMMENTS/CONDITIONS:C-L)AW,5- ( - --- --- -------------------------------------------------- ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE oa B� ov 9 �iv(� y3 �� sR#0o5 C-57_—_—_WC -----—-----WAIVER C57 LETTER OF AUTHORIZATION TC SIGN PER IT ENCROACHMENT DOC EHD 29-01 10/28/09 WELL PERMIT APP