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0 FILE COPY <br /> ...... SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q• 'a SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> q P. Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION 0 /4/ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v <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 /> '// � l , Assessor's <br /> Well Location OPO W, nun Cross Street s"I �S ��City Zip%5c/i�n/�(p Parcel#�j —d� <br /> Property/�I, n,' U11 60111 Cary I 4SW Phone#%G.! '543_23�2 <br /> Owner l NWV �VY� �✓1 G. Address tUlp �'*l'r �tY �Zlp(�r �" ,J <br /> C-57 Contractor (/• Address IZ39 M C OU 1}e Y4 City LL,, an Zip/,J�Lic#'10(08D Phone�g_ <br /> Consultant/Sub Cntr&�G Gt ATidress 240( Wfk�V• 'FIAT✓ City 0at�caltd Lic#Phone D,9—fP&3-4AP3 Z <br /> 0 0 saw-H, Range S a9"r Section � q <br /> GIS Coordinates:X`�Z./.438880 ,Y ������ .Township � 9 � — L— <br /> W RK TO BE PERFORMED: <br /> E ELL/BORING(CPT GEOPROBE, DROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#� ZC It rS }fj (D r �pO�4 ❑OVER-BORE DIAMETER <br /> ❑WELL# U ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: 40 / '✓ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING El HOLLOW STEM DIA.OF BOREHOLE �1 tl ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA:, <br /> ❑EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:EI STEEL I—]PVC El OTHER <br /> I <br /> ❑VAPOR E]MUD ROTARY DEPTH OF GROUT SEAL _ _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 /> )OOIL BORING )6HAND AUGER GROUT SPECIFICATIONS ywah <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVEPIPE <br /> CONDUCTOR CASING PROPOSED U (if YES,list specificajions 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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, all applicable California <br /> Title/Company <br /> Signed /�/� /I ,n <br /> Print ame A44/21 1 6L Lpioeo�-7 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: v �)9 <br /> WORK PLAN DATED: AWY <br /> APPLICATION ACCEPTED BY DATE ISSIfE <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED C # RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> Ab <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORI TION TO SIGN PERMIT ENCR ACHMENT DOC <br /> EHD 29-01 10128/09 WELL PERMIT APP <br />