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R�- <br />�' �"`�� SAN .JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 SAN JO <br />AQUIN COUN <br />� $fi _ R % Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.s' ov.H pEPA TM�11E41 IG ON <br />IT I <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 3242. S• M POrUC10 ST, Assessors <br />Cross Street ly`>' Avg City stoaktnn Zipy ZOb Parcel #_ 11U21 <br />Property Aro" <br />Owner ONO Contractors:. I n" O Address 711112 NQv� Dr. p City h Zip 493zo010 Phone # <br />C-57 Contractor VI `�\ Vva Address 7(�7� yin t r l� City 1 L^ Zip 9'S4L -Lic #5 1}� Phon�1 ^I)C1Q <br />Ittlnh o I <br />Consultant/Sub Cntr _MI 11CASMOW MVAddress 2124',g SJ= 6i"6 100 City Lic # 7i30Sb Phone 'tt4 -SqC4 <br />GIS Coordinates: X -120' 42,t!t0.6b it , Y 38" 0` 50.01 " Township IN Range (DE Section 2� <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 />5,WELL # —1 ❑ PRESSURE GROUT <br />[] *OTHER GROUT SPECIFICATIONS <br />COMMENTS: uMw-U1 <br />TYPE OF WELL <br />56 MONITORING <br />❑ EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />❑ SOIL BORING <br />❑ OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I(' <br />❑ HOLLOW STEM DIA. OF BOREHOLE j,/ ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL XPVC ❑ OTHER <br />❑ MUD ROTARY DEPTH OF GROUT SEAL �� TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />El PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED:Yes ❑ No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ HAND AUGER GROUT SPECIFICATIONS <br />rk <br />OTHER: ) i APPROX. BORING DEPTH <br />MNnIICTOR CASINQ PROP[ <br />3OLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />Y S, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I <br />Regulations, and all <br />Signed ! , <br />Print Name <br />prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />able California Laws. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />Title/Company <br />DEPARTMENT USE ONLY <br />I� <br />WORK PLAN DATED: J <br />APPLICATION ACCEPTED BY`s// ;G1a&C ,lO�e- O DATE <br />®ISSUED ����� �g AREA <br />GROUT INSPECTION BY �r/ �+1" �G oil'-�7�'9it FINAL INSPECTION BY le i) ij1d �17'A'gyATE 7 7� �,9 <br />DESTRUCTION INSPECTION BY <br />COMM ENTS/CONDITIONS: <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVICE # INVOICE <br />7/- 7/ <br />h' 9 <br />a- q <br />Fg?S-� <br />2 -e -L <br />4/a0aF <br />SR# 3 <br />C-57 WC -WAIVER <br />EHD 2M1 11/5/07 <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHM12N'NT DOC <br />WELL PERMIT APP <br />