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� SAN JOAQUIN COUNTY <br /> z �`r'—` ? EfvN-ii,'RONMENTAL HEALTH DEPARTII!-_-,gT <br /> SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �. �. .•P Telephone:(209)468-3454 Fax:(209) 468-3433 W UNIT IV <br /> q�/FpRa` <br /> WELL PERMIT APPLICA 1 � L' <br /> (, ! IL 01E6; <br /> COPY <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM AR IS�S�01 E`6; `` TT�� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work Hd� �I 'N i a bi L 41de in compliance with San <br /> Joaquin CountyY,;;, <br /> velopment Title,chapter 9-1115.3 and the Standards of San Joaquin County Envir rS QLh, WrE&nt.�y� /az//e <br /> -r%/�7�Zo LCV't e%� q� & Assessor's <br /> Well LocationO QST � Cross Street w� S City Zip ViZo9R Parcel# Jai .5�0 <br /> Propert r _ y <br /> Owner l�k_60yC� _ Address ` /90S_Alba S�, City F/e1W/'! Zip 9 ySS�Phone# <br /> C-57 Contractor ,//. Address qs� N��/ y ��II p�,3Lic#y S, ,�S_Phone 3/d <br /> L Cit /�1a/7 �Gz_ Zi <br /> ConWei friyo.- ops /uel6i <br /> Cons ultant-ShAsp6nlr �hs-�.�� Address��/{�jr R ��� City -C-eL471" LiC-9-- Phone70'.,7-W <br /> GIS Coordinates:X 37.93&94j6442Y -12f.29SG2G773?Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# s G/T /lit ai C ❑OVER-BORE DIAMETER <br /> WELL# ❑ PRESSURE GROUT <br /> [I*OTHER GROUT SPECIFICATIONS <br /> ❑ EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 3'❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> �e���//��yyfiYlz 7/eL//o <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS id TYPE OF CASING:❑STEEL ❑PVC jwprR>--* <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL Zo / TREMIE TYPE TO BE USED ti�E <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP ORfC_PT GROUT SEAL PUMPED:XYes ❑No (NO/TE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS PPO If(44.,� <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH -0 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify that 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. 1 <br /> Signed Title/Company jC <br /> ,rui/aita,eAf�c�SGiC'llti_C <br /> Print Name j��7��l�f- ]c �`�(o �; Date 7L// yz/o <br /> / DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: G 2-0 fin/• Cha r-fie r Way <br /> WORK PLAN DATED: D e-r-em l e r 21 Z O O 17 <br /> APPLICATION ACCEPTED B\/Y� �,�► c, �,,,�tt a MG (f a r+n e 1/ DATE`IS/SUED 22 AREA /459 <br /> GROUT INSPECTION BY V I P,� (?(�V 7 /w� FINAL INSPECTION BY V t �-� N6 �r DATE 8-g-/o <br /> DESTRUCTION INSPECTION BY r DATE <br /> COMMENTS/CONDITIONS: AdyaYleern ert,tL rJ CPT-19 61OT-26CET-21 UT-22 /122611 <br /> 0.PI -23 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> 41 <br /> 350 1 1.4- '7-22• io SR#006OS742 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />