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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> W: <br /> `X, 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> iP Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.or4/ehd UNIT IV <br /> ��/FOFRN <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 instaA the work described. This application is made in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the n ards of Sjn qui County Environmental Health Department. d <br /> I 8 ZK6 Ke f oil Cross Street C City 1,_ Zip . Z <br /> Assessols <br /> Well Location J71 Parcel#12 9' 0 D 0' 52 <br /> r n L / t� /� n b <br /> OwnertyP6 T ( ` 96tr V ft Address ?' 01 l/OW C1hyM 2d 10,sty% 71M/r1 Zip94sd3 Phone#175--HIS.43 SS <br /> 90 R �[ {� 9(Ic.grs, <br /> C-57 Contractor R DM <br /> //���Efn�d'�*Nw['/N�lAddress 102 tC/y U�OIOtI�f,4}f<< D(City 1�0 Zip95677 Li,#737071 Phone <br /> Consultant/Sub Cntr r'I1? CA U) J Address <br /> ,qO �ece-i I J f. �1 200 City 0 I >w'1 Lic# Phonel0'7,77`.oS s <br /> GIS Coordinates:X Y�ll.4�,Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELLIBORING(CPT, EOPROBE,HYDROPUNCH, AND-AUGE OTHER-) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> 8f SOIL BORING# I ❑OVER-BORE DIAMETER <br /> ❑WELL# I al Z 0. ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> �( / ❑EXPLOSIVES <br /> ��DETONATING CARD <br /> COMMENTS: 444A4 v �� T.J4Vf SA%L4 /A to. Z <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS to <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 HAle <br /> �'�4 C e eii m+ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH O T t T [1 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 /> 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 :dall applic C lifornia Laws. <br /> Signed Title/Company :ff �O �JS� IAR(Ab <br /> Print Name )S- <br /> O Date 7 /tel Z /Q <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Z l.�/ -16 /' <br /> APPLICATION ACCEPTED BY DAA ISS • �/ AREA nQ <br /> GROUT INSPECTION BY FINAL IN EC ION B 1" 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 PERMIT/SERVICE# INVOICE <br /> G1 ey. yff,&3!E .r SR# <br /> C-57 jffl WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 0/28/09 P <br /> DW <br /> FILE UPT <br />