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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street,Stockton,CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> LU WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - T <br /> i1EAL <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 /> Assessor's <br /> Well Location <br /> Cross Street City Zip Parcel# <br /> Property <br /> Owner TaranjiL S. Sandhu _ Address 34293 S. Cl=smar, Rd. City Tracy Zip 95376 Phone# 209-832-8692 <br /> C-57Contractor CGRS, Inc Address 5434 Dry Creek Rd City Sacramento Lic# 95838 Phone 916-991-1100 _ <br /> Consultant/Sub Cntr Address City Lic# Phone <br /> GIS Coordinates:X ,Y Township Range Section PAYMENT <br /> WORK TO BE PERFORMED: R t�E��_ <br /> ❑NEW W OILBOR I G(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) 4`. ED <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT �.�(� 3 <br /> ©-OTHER ELD Testing GROUT SPECIFICATIONS 1 <br /> COMMENTS: SAN./O CO�� <br /> ENV/A RO Ulla C O1jjV7y <br /> _ I:iil ._ P -- ET� � HRCTd aH PA <br /> At <br /> - - R MENT <br /> ti 3 ir':i: i R,.NE iSPL i11FCUSED '-'-UGEF LJ <br /> 0 AIR SPARGE/OZONE L PUSH POINT IGF OR-PT)-_ GROU li. :_L: Yes ❑Plo(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> �.SGiL BORING D HAND AUGER _ GROL `cC:IR�J.=TIONS <br /> M,OTHER: VF-CUL"" APPROX.BORING DEPTH <br /> ___....._._- ___. _ ❑BO ItD.R IC BO OR ❑STOVE PIPE <br /> COnoucrOR CASING PROPOSED (if E_.r:_F n .,,1 ,I.....R,e,l sego„) <br /> COMMENTS: - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 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,a appli. le Ca;orNa Laws. <br /> Signed K Title/Company ! <br /> Print Name Chris Murphy/ Date 12/26/08 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 3 146 2- S11 a SR#DOST 4 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ENCROACHMENT DOC <br /> DID 29-01 11/5107(WEB) WELL PERMIT APP <br /> sC : 3.)s . <br />