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pECE2oV#E COPY <br /> SAN JOAQUIN COUNTY <br /> I ENVIRONMENTAL HEALTH DEPARTMENPCl 0 7 2009 <br /> 600 East Main Street, Stockton, CA 95202- � I GpcF�rFtiT <br /> Telephone: (209)468-3449 Fax:(209)468-3433 Web:www. i[ HEAL IV TJ <br /> Ic <br /> WELL PERMIT APPLICATION nro�p � oG <br /> yQp` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GNFyr <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 /> Assessors <br /> Well LocattonS)2SS ELDoie4hD S% Cross Street MA7//EWS ROAD City 4E.JCFI CAMP Zip95 R3/ Parcel# <br /> Property <br /> Owner E0!'CA/r14 /ALbEz Address ?0. 8oX ;2$9 City fa5dnYCA71rP Zip S13/ Phone# 9/g;Z 0597'/ <br /> C-57 Contractor / Address AAo Al, ERST -C' City 4Jedb LAA/ Lic#T0233 Phone S3oaylgZ4 <br /> Consultant/Sub Cntr AIC ASsocIATfS Address//1/7 4-1JC 10#-m AY E City 1-40-4c-C7-0 Lic# Phone S79 22z./ <br /> GIS Coordinates:X� � ,Y —12-1• Township Range Section <br /> WO TO BE PERFORMED: <br /> 21 NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑5011L BORING# ❑OVER-BORE DIAMETER <br /> WELL# 9 ❑PRESSURE GROUT <br /> F]'OTHER yf//�[t'� GROUT SPECIFICATIONS <br /> COMMENTS: )62— <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING OLLOW STEM DIA.OF BOREHOLE _9" ❑MULTIPLE CASINGS El MULTI-LEVEL SWELL CASING DIA:� <br /> ❑EXTRACTION FI AIR HAMMER/DRIVEN CASING THICKNESS SC� 90 TYPE OF CASING:❑STEEL LIPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL -2 6' TREMIE TYPE TO BE USED O-AUGERS❑HOSE <br /> AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS PO.C7LAND CEYN EA/1 fFaoV&- )5EAA:3N 1—, 6- <br /> OTHER: <br /> :EOTHER: ❑OTHER: APPROX.BORING DEPTH 3S OLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,11 s9etlfi s inwmmentsedion) <br /> COMMENTS: SEd< A79:: ASteC,A�'ES ei4o7 -re-SnLW6 WzIAK PLAN DATA e9 <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 poltl.tion and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all ap n s Califo a .aws. <br /> Signed /✓.� Title/Company E.vr 04 ('Gp[O i37 G A55o Gr A?E� <br /> Print Name Date /o <br /> p DEPPARTM,E.NT/USE ONLY J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 8/25 S C��i� � d7 AA/R.N C747N!/ C�/Q�`^"-�•' <br /> WORK PLAN DATED: 10 <br /> APPLICATION ACCEPTED BY DATE ISSUED /V 8 Q 2 AREA Q6 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHI** RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> 2JC)j IMW , C Vr.— LY1101 sR##0584R <br /> C-57 WC Vr -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN P RMI ENCROACHMENT DOC <br /> EHD29-0111/5)07(WEB) FILE CO"ERMIT APP <br />