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" AiLE COPY <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENIPR 2 ZO10 SITE <br /> :a <br /> A11TIGATION <br /> 600 East Main Street, Stockton, CA 95202-3029 1 L► <br /> •, Telephone:(209)468-3454 Fax:(209)468-3433 Web:www s, iT UNIT IV <br /> WELL PERMIT APPLICATION <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 Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> WeIlLocation i5Q l VJ-Ckor1 W V�cwCrossstreet S. Frosn.n_A�enu-ce._City `�-kc- {-on Zip R j2U(v roe I Lo3 �5'70/(,a <br /> Property U <br /> Owner Fv PY) h LCt rYi r 1 (�. Address 1'o i y'1-(_h0"-lu Wk&a+ City '�-iz O Lk n _ Zip G Zo(o Phone#�%o c��)q Fis-��1`{G <br /> C-57 Contractor \� � 1&)_D6' Ilir1�� Address 5?)D(o DuC__(J1-de-11"l City `5kT, o� Zip 9!5 -4z l 'hone <br /> onsultan Sub Cntr�(ou r if 7o ro Address (114- M 0n 1�4,a e f City L�cl sr_ Lic#Ply 3y1 Y_Phoney 9)k 38-IXSS <br /> GIS Coordinates:X Y Township W 4,4 Range _Section N 6 <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ®DESTRUCTION(CHOOSE TYPE BELOW) <br /> gSOIL BORING# OVER-BORE DIAMETER 9-In(° (M W­3) <br /> WELL# PRESSURE GROUT MW 1 MSU Z.,Mw q rvi W.-S <br /> ❑ <br /> *OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: -P'-P,J 0 e'mnr-l-o(.✓) �A wel(s.` C_atfi 7 YYe_+Cr (An/A 5(!PLP'nP_G( liwy__ in � 3D�-eA <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑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 301) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,ht spedttcations in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify th1j have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and 11 ap ble California Laws. <br /> Signed -p Tide/Company�, C9wIA nr e ro Ana fsl is; Ir)e-. <br /> Print Name Er t 1 t-I C 2- Date g (D <br /> DEPARTMENT U§9 ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: g�2,( <br /> WORK PLAN DATED: `7,D—2'0 1V <br /> APPLICATION ACCEPTED BY DATE I IMWEA�W <br /> GROUT INSPECTION BY Viefoei& Me 5-13e. FINAL INSPECTION BY DATE <br /> -fvrVi tfori w M cCdrMoy <br /> DESTRUCTION INSPECTION�P'N' ;d.-S <br /> 5-13-10 DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 105 ., 3 of 4 s -Z f <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SI MI CHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />