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-� � 1 4 2010 <br /> SAN JOAQUIN COUNTY ENVIRUIVIVILN F HEAL T" <br /> ENVIRONMENTAL HEALTH DEPARTMENtHMIT/SERWCES SITE <br /> _ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT I\/ <br /> ��FORc� <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 wilh San <br /> Joaquin County Development Title.chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> SL,,� � V- S�-R-& 'D \', Assessor's <br /> Well Location�� i'o\ G.3h�S� Cross StreeW C,�2 c -�w'�>C city S-�S, —',zip Parcel# <br /> Prope _ \ \ <br /> Owner e3 d o� 7��/�S^�f'�Address g35� @Jt�o.�R.�Y. C�ity �-Y� 1 Zip Phone# <br /> C-57 Contractor��'A& f nuc Address�J�h S Lyy ..•� laity <br /> Consultant/Sub Cnh(�"N.,��' 5---- Address-" V——e,S A 'V� City C"' Lie# Phone <br /> NIS Coordl'Q.:X — 'y ,Township `('j Range V2-St, Section C <br /> WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BOR G# ❑OVER-BORE DIAMETER <br /> [S�WELL# ❑PRESSURE GROUT <br /> -I�,•OTHER U\� .. W S T J.r� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WEA L INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 18 MONITORING HOLLOW STEM DIA.OF BOREHOLE S11 ❑MULTIPLE CASINGS❑MULTI-LEVEL <br /> ��WELL CASING DIA y <br /> ❑EXTRACTION ❑AIR HAMMER/DRNEN CASING THICKNESS S�� TYPE OF CASING:❑STEEL b/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 WHO (NOTE:MAXIMUM FREIE-'FALL D PTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS +�Cgt-J ,�V N� nDM�N�M 1 <br /> ❑OTHER: El OTHER: APPROX.BORING DEPTH .L 5 `�C ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,Ilsl specifications In comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> fi 'ORKI OURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify t I have prey ed t Is applic iona d that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, SII ap /1z ati. r la Law <br /> Signed ! �-y/ % Title/Company i~ rE�C124K44"�f' <br /> Print NameDate /`-IL%d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Leo A (l.W(SLt'� 'ate <br /> APPLICATION ACCEPTED BY DATE ISSUED I AREA -4110%M <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CON DiTI ONS: <br /> ACCOUNTING ONLY: AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Z`l I t $�•Ott g�. rYt� Z Y*> I t s`c J S R##o 0501 L't <br /> C-57 WC �/ -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29A1 1115107(WEB) WELL PERMIT APP <br />