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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> r-„ �, 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> AUG 2 1 2009 WELL PERMIT APPLICATION <br /> ENVIRONMENT HEALT40N-REFUNDA13LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERMIT/SERVICES <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 compliancewith San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 1 �, Assessor's <br /> Well Location <br /> 5 ()hi`IS C�y Su/d« Cross Street f°✓�S' "fes�cN�S City � ��•� Zip Parcel# <br /> Property 9�3g <br /> Owner ��`�d/: `.!o<J¢5 �a.M� 1 Address �l/lx n�/6 17 City A5i—oa 7-0,J Zip SPG Phone# 04192601- <br /> �P.Ef /t'It Address q>,' f/O�nl�i '6 City /7/Vr iA)i4Z Li <br /> c#���/�S Phone 0z3_-_)3/3-5-?00C-57 Contractor ) <br /> Consultant/Sub Cntr ? iE✓f:Go�M�s.�! Address 3"-/ 'em 65S 4 City CiPB� Lic# Phone ((Zoq/S�7 <br /> GIS Coordinates:X 'y Township / tj Range_ff/Section /67 <br /> WORK TO BE PERFORMED: <br /> INEW WELL/BORING(CPT,GEOPROBE YDROPUNC )HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> 19: 150 SOIL BORING# C ❑OVER-BORE DIAMETER <br /> WELL# ❑PRESSURE GROUT <br /> ❑ <br /> *OTHER GROUT SPECIFICATIONS <br /> COMMENTS: �oE'i^i(S /J /i�: rk'QUTYO Int TN C�M�nl! <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <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 4PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORJJ.��G� ❑HAND AUGER GROUT SPECIFICATIONS <br /> • VI.L'C0'NW�SSrMC�i <br /> 7.OTHER:how i ❑OTHER: APPROX.BORING DEPTH aU-P•S FJ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 191 0,1%M15 51"jC%_ 0'nelZ &'40(4 <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 /> Regulapiens,and all applicable California Laws. //-++ <br /> Signed Title/Compantly" to(- 0 A 6e,,&n f t-f <br /> Print Na gh i117 CSL" r' Date 8 <br /> DEPARTMENT <br /> `USE <br /> _ ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY1 c7�` '� DATE I UED / O AREA (0/ <br /> GROUT INSPECTION BY FINAL INSPECTION BY 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 /> SR# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />