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1 0 0 P, P"' '� y� - - <br />�'eb <br />SAN JOAQUIN COUNTY <br />UN 2 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />} A 600 East Main Street, Stockton, CA 95202-3029AN JOAa�IN CODA MIThION <br />c t <br />I Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.s' &% RTMENT -rfHEALI 171 L' <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 6242.9-E1 DOM& G1" <br />Cross Street IV`{ A\16City <br />G oato(A <br />Zip 41&.2010Pa Parcel 11,110202°( <br />Property <br />Owner cede CVAAT6I(* 'InG <br />Address ),ill 11`441y Pr, <br />City t0(A'ton <br />Zip 44SX10 Phone# )Af4-'t4Z-84% <br />9$ <br />C-57 Contractor Aka <br />Address"5 tf^J <br />0 I - L'l'r( e <br />City C Uy <br />Zipq! "14 Ztic # � ' WhonS91 1)� <br />❑ AIR SPARGE/OZONE <br />. <br />GROUT SEAL PUMPED:'0 Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />f} <br />7 <br />Consultant/SubCntr M111CIr gro0Vsthy <br />.Address zlzMalnst cke *A0 <br />ti <br />City <br />Lic # 'Fla0i1P' Phone 'Ily� S'Du • �{S4 <br />GIS Coordinates: X '1�" qZ j0.5W' <br />, Y 3?" 0' 50 01 t Township <br />IN <br />Range VE Section _20 <br />WORK TO BE PERFORMED: <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />q4VELL # PRESSURE GROUT <br />❑ *OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />TYPE OF WELL <br />INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS D <br />90 MONITORING <br />El HOLLOW STEM <br />DIA. OF BOREHOLE -$L ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ EXTRACTION <br />❑ AIR HAMMER/DRIVEN <br />CASING THICKNESS -% TYPE OF CASING: ❑ STEEL[ PVC ❑ OTHER <br />❑ VAPOR <br />❑ MUD ROTARY <br />DEPTH OF GROUT SEAL_ TREMIE TYPE TO BE USED ❑\AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE <br />❑ PUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPED:'0 Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING <br />❑ HAND AUGER <br />GROUT SPECIFICATIONS Gtm L,'Clk V�'y�h ) <br />❑ OTHER: <br />OTHER: `; 20hY / <br />APPROX. BORING DEPTH i 6 l BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />' <br />C ND�cTOR CASING PROPOSED (' YES, list specifications in comment section) <br />COMMENTS: <br />Al <br />y } <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all a <br />licabbe California Laws. <br />Signed <br />��� �- <br />Title/Company Mlle.+'0 �1vlrOnmUiTal Imo' <br />Print Name effr �Benn�t r <br />Date <br />DEPARTMENT USE ONLY <br />"&A^ - 70" 71908 _ <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BYE/� d DATE IISSSU/ED 6 <br />GROUT INSPECTION BY 1:�rcI �;r fs2.,eFINAL INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />DATE <br />CONjMENTS/CONDITIONS: /�:�jf r!' <" c <br />"WW/ -10A Z�g <br />OA AREA <br />1!5+-413ATE �S� �$ <br />t7 pg <br />00re4�104�1 %� Q`._04 <br />ACCOUNTING ONLY: <br />AID # FAC # C T <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # RECV'D BY <br />DATE <br />PERMIT/SERVICE # INVOICE <br />C-57 WC, -WAIVER <br />EHD 29-01 1115/07 <br />0 <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />