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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION • ., _ P Telephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd S�ipR�a� 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 Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. nn'' 11 '1 ) �-1 Assessor's Well Location 5�� lac r r W� Cross Street L;H C.IX s4. Citys4 cAiZip 20c Parcel#144-M 4-M •-00-000 Property }l t1 Owner.]��x �r� Address �$0� Ayy TCyP, City Zip 95206 Phone# A 16 C-57 Contractor 11Address? . st,,+ City6)'JU Zip- 7'h Lic# O 3 hone ConsultanUSub Cntrs1w Address ;e,,e t1WU City CAbhCzJ 945ZO Lic#$S Phone QZ5 7M-979V GIS Coordinates:X Y Township Range Section WORK TO BE PERFORMED: NEW WELU13ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER, THER' El DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING# ❑OVER-BORE DIAMETER 'R WELL# VA-7,� SRz, •3 SpT_ ❑PRESSURE GROUT ; OTHER o ,w �} �j� '^^'�,�t1�l" GROUT SPECIFICATIONS ❑EXPLOSIVES DETONATtNG CARD COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING HOLLOW STEM DIA.OF BOREHOLE rr " ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA:_ ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS �,�,�� TYPE OF CASING:❑STEEL PVC ❑ OTHER Arm spar -yb'b ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TftMIE TYPE TO BE USED AUGERS HOSE � sS El19AIR SPARGE/OZONZLI, El PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED: Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONSIDbeli- r3 40 El OTHER: ❑OTHER: APPROX.BORING DEPTH t ❑BOLTED TRAFFIC BOX OR []STOVEPIPE CONDUCTOR CASING PROPOSED (if YES list specs lio s in c mment section) COMMENTS:I ysir 5a.� �YJ�t r r�� 1� 7 / ��-�� l � �T llsa Or •ll� 7 r b,s Us MSH— Lyl A..c�., NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 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,and all applicable California Lqws. f Tide/Company Signed P y Print Name i Date SAA, C2 DEPARTMENT USE ONLY R ' ,. SITE MAP IN UNIT IV FILE,ADDRESS: SIS Gv� -ice ze WORK PLAN DATED: 4s 31 0�1 APPLICATION ACCEPTED BY DATE ISSUED Z Z AREA GROUT INSPECTION BY l[1�3d�t�✓l FINAL INSPECTION BY DATE DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: i ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE PERMIT/SERVICE# INVOICE j 2°(0l $`j .no 6 z 12�I a SR#5 -3 3 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 10/28/09 WELL PERMIT APP I I i