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$int SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT PAYMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 RECEIVE[MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: WWW.sjAOV. h UNIT IV <br />! { � z 0 2009 <br />WELL PERMIT APPLICATION SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />kinkl_DCn I1NIMAQ1 C DCDRAIT CVDIDCQ n VGAD conRA nATr I�c HP-A�-TH DEPARTMENT <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 II -1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessor's <br />Well Location : LI I�i,.,:�-(Cl1e Ku '� Cross Street 11L�ni1�i i k ^[4C1 City (,t''t irpl2 Zip `S "�L Parcel # 7_ `j C`?3l> f?`� <br />Property <br />owner Vei ryl,16 4--iyA hers Lli b -' Ce Address 3_=j o l S 'Bj'yd Roar( City I Yt70U Zips , Phone # <br />(!C'nmcx' f ur Sanck in,. <br />C-57 Contractor kcijs,-,n, r, CoeAddress 83-7 3iw4:' R'oo(! City .gitt'k n Zip S2'S Lic# (I' Phone <br />Consultant/SUbCntrfl,vlhlnr,tl f;kEjji;. rte n1',mlAddress_ _.j 7 Sh(tw Pto(J City 9)A'-gkn Lic#' Phone �ZCI-Q(,11- I11L(1I <br />GIS Coordinates: X <br />,Y <br />, Township <br />WORK TO BE PERFORMED: <br />NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />.SOIL BORING# i l 13 t73 f_��4 <br />❑ WELL # <br />❑ *OTHER <br />TYPE OF WELL <br />❑ MONITORING <br />❑ EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />Range Section <br />❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ OVER -BORE DIAMETER <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />❑ HOLLOW STEM DIA. OF BOREHOLE 1, 2.'5 " ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: <br />❑ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL ❑ PVC ❑ OTHER <br />❑ MUD ROTARY DEPTH OF GROUT SEAL( TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />f9 PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes ISI No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />b, SOIL BORING ❑ HAND AUGER <br />❑ OTHER: ❑ OTHER: <br />COMMENTS: <br />GROUT SPECIFICATIONS 1 U 0e th l UI Ctt 0 e �L 1 l� <br />APPROX. BORING DEPTH �T - ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED L' (if YES, 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 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, an",appii le li mia Laws. <br />Signed ti` Title/Company h 1 ( °Y0 e %I' ili <br />Print Name - ;YWalu Date I I <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT& FILE, ADDRESS: 0L( S Sck"�c Loch ,J o p JAN 2 CUUy <br />WORK PLAN DATED: 3�osFN�ilFiiifi�E'd-1 1�PALTH <br />APPLICATION ACCEPTED BY �/41 �0 1 C)()(Q G DATEISSUED PER /,;L. <br />itl1`,:;c_'vAlzkk <br />GROUT INSPECTION BY C) FINAL INSPECTION BY�1j2AJ_V DATE 2— <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: "7 G�+I SGL' �Q We US, 13 -1 6 2 13-3, 4 (3-- 11 , FG <br />w t U, &4L ,Pis' f IA.vt d Ct-,, t4 <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 />[_S7 \A!!` <br />uin loco <br />10 � <br />SR# 605,6 <br />i.af LC I I rK Ur AU I MUKILA I IUN I U SIGN PERMIT <br />EHD 29-01 11/5/07 <br />ENCROACHMENT DOC <br />WELL PERMIT APP <br />