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.e <br /> San Joaquin County <br /> = Environmental Health Department JAN 2 6 2009 SITE � <br /> { 600 East Main Street,Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.bz"FJ)NMENT HEALTH UNIT IV f <br /> Well permit Application PERMIMERVICES <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 Tale,Chapter 0.11153 and the Standarde�t Gan,:oaquin County Environmental Hearth Department. <br /> b d 2- Assessors <br /> WELLLocationQ_r�D �f; �lL^'Sa^49 6 Lygo"T+y <br /> go, Ce*•e✓ Zip Sr2o Parol# /vim <br /> PROPE Y u SftxlG� Zi SzcZ P <br /> Owner!— <br /> d"... <br /> Z�N Ll J�prat�� Cty o. P� — hones Z_O�t'a13�-$36(, <br /> C•57 Contractor A :Nx Add+ess ?G 3� bnt E C C 1t+rCL6 City ^'W•�°sly a f 1421ic#�� Sj�Phone#gI L G L Z <br /> Xr C°so..r� 9111 [(41-,0q.00 <br /> Consultant I Sub Cntr 7Aa+T tc_ Address. C11 �• C+�V c;tytQANcyo Lic# Phone# J <br /> �o <br /> GIS Coordinates.X Y Township Range Section <br /> WORK TO BE PERFORMED" <br /> p NEW WELL i BORING (CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') W ESTRUCTION (choose type below) <br /> p SOIL BORING# n OVER-BORE. DIAMETER <br /> p WELL# j4ESSURE GROUT <br /> p*OtherGROUT SPECIFICATIONS <br /> COMMENTS k'ICLL. l31I'-�� LOCA'r1tO ON WrtIA, 16F-I• 4,F_- 03^ J�A�t��Tln� <br /> TY OF WELL INSTALLATION TYPE CONSTRUCTIO11§PECIFICATIONS TT LL CASING DIA:? <br /> MONITORING p HOLLOW STEM DIA,OF BOREHOLE ti MULTIPLE CASINGS p MULTI-LEVEL VYEJ_'a <br /> p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS 5Ck 4 D TYPE OF CASING: 0 STEEL C a OTHER; <br /> p VAPOR p MUD ROTARY DEPTH OF GROUT SEAL �tCr TREMIE TYPE TO BE USED: p AUGERS OSE <br /> p AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS—^ W <br /> p OTHER—__a OTHER APPROX.BORING DEPT "Ct t # 0 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> r r CONDUCTOR CASING PROOPOSED j u (it YES,list specifications in comment section) <br /> COMMENTS:, tA5C:4 Cg t17 11' Sr� J-A t['1r��1�t11 �ee17Ild J,6u -5*11114 Ila <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 Ordfrian es,Iqa .a cl e�gulations,and all applicable California State Laws. <br /> S,gnedz_r`_,_ �._ .__...__ _TitleiCompany� 7 ^'�"�' C-v�✓lva �drCr�.rs�rzo .y <br /> Print Names Ifu � 'Z tCp.+�SG 4 Date <br /> t--D'"EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DR SS: X-to g (2yK 14VI+ r 5 (-,c cQt1. <br /> WORK PLAN DATED: I2 <br /> Apphcalinn Accepted By_� _Date Issued <br /> Grout Inspection By_____-, _Oatc��."_�_—Final inspection By <br /> Deslrucl*n Inspection By Date <br /> COMMENTS I CONDITIONS:__ <br /> ACCOUNTING ONLY AIDS FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3 SR# 5�3` 9 <br /> C-57_T WC--WAIVER_. C-57 Letter of Authorization to sign permit• Encroachment doc_ <br /> I ttl),v,`.no WEB <br /> 90 t x200 7 <br />