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San Joaquin County <br />n + >3T-;erAvenue,3rd <br />mental Health Department <br />11x1111 �! lyasFloor, Stockton, CA 95202 <br />[�JA 209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />1 2009 Well Permit Application <br />ORIGINAL <br />SITE <br />MITIGATION <br />UNIT IV <br />BVIRONI F � • COS <br />r ^ NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />iJ � J C� l uv PE PvSI l <br />Application is h by ma to an Joaquin Cbdntq'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 />f <br />("--try C Ill.�3� `/' Assessors <br />y/ <br />WELL Location l� i �y IZ :y/�t of << 7 Cross Street R�d e Aje- City s ivc k- iX' Zip '?S-2"' Parcel# <br />PROPERTY r( <br />Owner [��4g of S fuck {-0., Address `-�L& �� �o ado Cit 5� -g N Zi 9Sz0`� <br />-� y p Phone# Z o 9- 9j 7- !'21 Z <br />C-57 Contractor re� D r'dl wu Address y -1 r Ce ry i tus /fire City S; K� I i�:l( Zip `Z0*76 Lic# 6 Sb 'O'Phone# 6-6 Z- %Z7- X 899 <br />Consultant / Sub Cntr'SalOiQ Li.}G/haIo:.a)Address.4SO17KdI c,,eRd*100aHcaJ <br />Cityei' Lic# Phone# <br />GIS Coordinates: X <br />Township <br />Range <br />Section <br />WORK TO BE PERF I fV"!! ` <br />btNEW WELL fI3ORINGy CP , GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />SOIL BORING # C P ! -3 0 OVER -BORE. DIAMETER <br />ELL # KJ�� 11 0 PRESSURE GROUT <br />0 "Other GROUT SPECIFICATIONS <br />COMMENTS: _ <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Zi ' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL VO rr TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE _- <br />0 AIR SPARGE/ OZONE PUSH POINT (GP orO)GROUT SEAL PUMPED: 'Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />Q'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS «�e.t t <br />0 OTHER:_o OTHER APPROX. BORING DEPTH /10 f C - 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED q/J (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 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 �es t Title/Company_ 5etc'3Q w4( - <br />Print Name Ci r" o.-, r ` v : Date Z <br />DEPARTMENT USE ONLY zoo <br />SITE MAP IN UNIT IV FILE, ADDRESS: C,�t LXX/ .' <br />WORK PLAN DATED: O (�, <br />Application Accepted By Date Issued �2 (�� Area <br />Grout Inspection By Date Final Inspection By Date -!Js <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER .REQUEST # <br />INVOICE <br />M <br />-�- <br />&t to �i <br />S R# c/l <br />C-57 ✓ WC ✓ -WAIVER_ C-57 Letter of Authorization to sign permit ✓ Encroachment doc`a2 G- <br />EHD 29-02-001 � ) os- Ol La <br />6/22/04 <br />