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�an Joaquin County <br />Environmental Health Department SITE <br />600 East Main Street, Stockton, CA 95202-3029 APR _ i 2CWTIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd YPIT IV <br />Well Permit Application ENVIRONMENT HEAL II <br />PERMIT/SERVIGES <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 with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location ?(P S6 MGnfe 7)iCthly I4uonue Cross Street NbrWi Rurio Awhiarity 54b6klbn Zip q5pc3 Parcel# )33- /1/ - 3/ <br />PROPERTY <br />Owner tiaW ',91)a2ia khan Address 59 Mirahttli Ciyele City _Sen .)05t Zip qTi iq Phone# L1Dy•AgI- 114y <br />C-57 Contractor f)duanrml rwbtnuu Amtrt4gl,loAddress U7 .9haa{ Rnrad City 9ka1at Zip gI5-.0155 Lic# :2?. -i Phone# ?Oq- q67 -loo <br />Consultant/ Sub CntrAdyilliNejQrn/r„";rennv,iAfievAddress 83'1 Show goad City j&kjr Lic# 62022-1 Phone# ?09-f11t7-106(0 <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />*NEW WELL / BORING (CPT GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />,WSOIL BORING # VI- $ VI , VI -it) : B -n. -Q, 13-13 0 OVER -BORE. DIAMETER <br />0 WELL # 0 PRESSURE GROUT <br />0 *Other GROUT SPECIFICATIONS t\ <br />COMMENTS: glPtvinee ltVvk Plans C&Ipel .260-7 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 1.,75" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: NIA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS W4 TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: u I fA <br />VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 'V � 'o'b- TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE C <br />0 AIR SPARGE/ OZONE x]ePUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes J rNo ( OTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />�,Q�SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS e ? 1 2 1�rr�turd NPOc} r1 rvyn 4 <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH;5'bs!A BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED IJIA (if YES, list specifications in comment section) <br />COMMENTS: RP(eyene-o IWYP- Plam Nalld 93 )anuajA anba IF? 0" Lha- 06®7 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. �5 <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. C <br />1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x_ '&1( ;I-Title/Company ViCe 'l� ielenf / 9C-1UClrV1&i 0eo(:ni,irDr'Mrn+a.(, /ne . <br />Print Name A261jtid �. M r" Date 'l1' / Gk <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: -L&SO, howl -t-. btOJ4'a <br />WORK PLAN DATED::�r,j0/l-ta`�o� L0, Lk,R-tl is -lam) i`zS(,7S (y�-B,Vt•O1, V4-tJ ) <br />Application Accepted By ' ,t—ncv>�L 1 .1� �.,.J� I Date Issued A J Area �b ` <br />Grout Inspection By _— Date Final Inspection By Date 41a1. o <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMFf QUEST # <br />INVOICE <br />Seo <br />-o) zl$zi'V`� <br />I <br />C-57 WC,--_- WAIVER_ <br />EHD 29-02-001 WEB <br />9/11/2007 <br />C-57 Letter of Authorization to sign permit_ <br />