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• SAN JOAQUIN COUNTY 40 <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Wwauhone: (209)468-3454 Fax:(209)468-3433 Web:vrww.siaov.orglehd UNIT IV <br /> 1FOR <br /> DEC 15 2009 WELL PERMIT APPLICATION <br /> ENVIRONMENT MEALT N-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application i �i 'Title,chapter <br /> County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin Co,"t ,eto fent Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department- <br /> 17 3 4 S �. Assessor's <br /> Well Location 12:-v ; 5ek _ Cross Street !' r,LL i 0Tc� City OL T Zip �1 Z Parcel# <br /> Property cf � ilt <br /> Owner : RAA <br /> Aa� Address 12� �� �Trtazt City tA C, A Zip 153•`3 Phone# -Z1 <br /> C-57 Contractor PjWp�cl�e y Address 12-39 AL,-�*- . l <br /> ST, A city Zip�1,5'77L Lic# 0 `' Phone <br /> ConsultanllSub Cntr Af t', Address ZZs 3 #-tc a- City _�Acxc Lic# Phone`iIIf'`1'-i - V(IOf <br /> GIS Coordinates:X-%'L1411'L4 Y 39, 10 tri Township 4-0 Range Section 2-4 <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# OVER-BORE DIAMETER <br /> WELL# PRESSURE GROUT ydetr •.v-�"+ <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS: <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 HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> OAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Li--/ TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: C]OTHER: APPROX.BORING DEPTH t - ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONOUCTOR 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 prepared this apOcation and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a vlapplicable California IlLaws. �& `` A <br /> `t T S`1 Title/Company C7 ke� �-5 1 A 6;L- rp V ' l�-y" <br /> Signed —� w f---- <br /> Print Name L-Aw) Flim Date I"L Ito 105 <br /> � <br /> _ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD ESS: ��-3Li <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED �i a AREA <br /> GROUT INSPECTION BY41� FINAL INSPECTION BY I v DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: �:-�,�Q �L { <br /> COUNTING ONLY: AID# FAC# <br /> IE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 01 J 0 IS SR#X8`18 <br /> C-57 WC -WAIVER C67 LETTER OF AUTHORIZATION TO SIGN PERt4T ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />