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YEAR FROM DATE ISSUED <br />I the work described. This application is made in compliance with San <br />County Environmental Health Department. <br />Assessor's <br />City C'- c'— erC 24 Parcel # j (,)--0 (02-- <br />SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br />C[E- 5,0 600 East Main Street, Stockton, CA 95202-3029 <br /> <br />tep ne: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br /> <br />FEB 13 2009 WELL PERMIT APPLICATION <br />ENVIRONMENT HE41161_REFUNDABLE PERMIT EXPIRES 1 <br />PERMIT/SiERVICE: <br />Application is hereby made to an Joaquin County for a permit to construct and/or instal <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin <br />Well Location .17----1-‹ 44-';<-1 'Cross Street vIckct, <br />Property <br />Owner '20..• 4 it"c'e 4-P-4.• Address '7 7 .0 I )) <br />C-57 Contractor -RV c ‹.• Address / C u•Y <br />5.4,— • s <br />Consultant/Sub Cntr 7 <br />Address City <br />SITE <br />MITIGATION <br />UNIT IV <br />City Zip.1<;74/1> Phone # 7s 114'41 t <br />City Lic #1363g7Phone <br />Lic # Phone <br />GIS Coordinates: X , Y ,Township Range Section <br />W RK TO BE PER7OkIVIED: /) <br />NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />0 SOIL BORING# <br />KWELL # 1 2, " - a - -\-,c ,,,c 0 C. <br />0 *OTHER <br />COMMENTS: <br />DESTRUCTION (CHOOSE TYPE BELOW) <br />7r1 OVER-BORE DIAMETEP <br />'PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />KNONITORING HOLLOW STEM DIA. OF BOREHOLE 9 '' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS C••"14 si-61 TYPE OF CASING: 0 STEEL (XPVC 0 OTHER <br />A <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 5 - 7 0 TREMIE TYPE TO BE USED 0 AUGERS HOSE <br />0 AIR SPARGE/OZONE 0 PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: 0 Yes Z No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 4- \--,-,--:. e 1,,„-C-‘0--,1. ': <br />6 0 <br />El OTHER: 0 OTHER: APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX OR 0 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 pre this application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulc7d all appli7 <br />Print Name <br />Signed <br />ornia Laws. <br />r <br /> Date lt ((DI <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: (9-<.2101 P <br /> <br />C <br />WORK PLAN DATED: 1)-CL Ct 2-00X <br />APPLICATION ACCEPTED BY kliCA.*--a <br /> <br />DATE ISSUED <br /> <br />AREA I e 7 <br />GROUT INSPECTION BY FINAL INSPECTION BY <br /> <br />DATE <br />DESTRUCTION INSPECTION BY-14-11-r- DATE <br />COMMENTS/CONDITIONS: /‘:.; 0A—do, St' Kkoca2—g -ioep <br /> <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />d-(0) n / 84 — Yri — i'3.z 1 Air .07//)(1 sR# 60 (-6c;?, <br />WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC C-57 <br />EHD 29-01 11/5/07 (WEB) WELL PERMIT APP <br />re. <br />le Cal' <br />Title/Company