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6 0 "q�Iy SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT� SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.siciov.org/ehd UNIT IV WELL PERMIT APPLICATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Joaquin County DgyelgpmanI Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ,^ t{eoo:ru�*.tSVt £.- r-� T�>:,F K.aL Assessor's O,,*,, .-t L,e Well Location .r ix, .... d.ct Cross Street 8 Ak.Ly Imo�� Citytyy� J-i'a L;t,'�e^- Zip Parcel# nGq.^Aoa1 Property, V #2oy4 Tl- C _ Owner F'-c z l:.��•Fw,_ b.,•t, Address '�'Z-{ r t r 9ai�d-e J f'.f City S3-o _fc F ,w Zip`�5 X 0,3 Phone#(91 E�`fS6- •{4 e o C-57Contractor Pe. c.': y-I1_' 4dress fL9 'a A1,*ct. 54... IH.ACityv14nAld..of Zip45-7-7}6 Lic# g6jC" ?Phone Consultant/Sub Cntr :,,/G fP,- Address 5 5- �• 4'�^•;- •r•�, bty, LDoLic# 804-0 Phone(Z-G cl�33y'S 363^L3p GIS Coordinates:X r Z.I e t W S 1., ,Y :73 OZI 40.1 ,Township Range Section WORK TO BE PERFORMED: j NEW WELLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) SOIL BORING# Zl.-� f ❑OVER-BORE DIAMETER ❑WELL# ❑PRESSURE GROUT ❑'OTHER GROUT SPECIFICATIONS ❑EXPLOSIVES DETONATING CARD p COMMENTS: 00-'e- J'aI h� n>'.1ry .. u c G TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ! ❑MONITORING ❑HOLLOW STEM DIA OF BOREHOLE L ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS t4ly\ TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Zr TREMIE TYPE TO BE USED❑AUGERS[I HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes 004o (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') �I SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS A— f ❑OTHER: ❑OTHER: APPROX.BORING DEPTHZS S� [I BOLTED TRAFFIC BOX OR 0 STOVE PIPE COMMENTS: t�Ml`/1 CO UCTORCASI FROPOSED (If YES,list spe�ralbns In v rnent sedm) 41.tx Jtt.44 64 •JJ.Lk, Gtw,.frr NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,a all applicable Calif rota Laws. T. Gt.\. WCC Signed Title/Company ' Print Name Date 5'- ZZ-' f O DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: 1Gaot,& WORK PLAN DATED: rZ I J APPLICATION ACCEPTED BY DAT ISSUED 2�! O AREA 3 t'1, GROUT INSPECTION BY FINAL INSPECTION BY�t�� DATE Wit, 11 LJ DESTRUCTION INSPECTION BY DATE �� COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE.CODES FEE INFO AMT REMITTED CHECK# RECV•D BY DATE PERMITISERVICE# INVOICE SR#S'RS$'1- G57V WC -WAIVER C57 LETTER OF AUTHORIZA ION TO SIGN PERMITyr ENCROACHMENT DO EHD 29-01 10/28/09 WELL PERMIT APP