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0 0 <br /> ur <br /> SAN JOAQUIN COUNTY <br /> �IIhI`,Vr/2 l ENVIRONMENTAL HEALTH DEPARTMENT ------ <br /> �u V �� <br /> r 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW,s'Gov.Ont/ehd MITIGATION <br /> JUN 11 2009 <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> ENVIRONMENT HEALTH -- <br /> PERPJiIT/SERVICE ON- EFUNDABLE PERMIT EXPIRES 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 /> Well Location .�yb N Q2(Aw"""cross Street W• FvC I,O AvP, <br /> CityOCk'rz ZI Assessor's <br /> Property dress Z.Zt # --- P �s?Oy Parcel# <br /> Owner IZE.�9 ppb i R TUXeCO CT. <br /> II-- A Ci eS+171-fir Zip 9 Phone# <br /> C-57 Contractor / ^^ Address • [) S(A,yL� Plryi — —_ <br /> Consultant/Sub Cntr J(LE�NFELDFQ city "—�l _ Lic# 6 r -zz33 _ <br /> Phone <br /> Address 2cb1 /•}Roh-/J•ltPQZv- 00ci .SiQ.kTO/1 <br /> GIS Coordinates:X y ty Uc# N67ISIPhone • 9- 48. 1$y5' <br /> -- Township <br /> WORK TO BE PERFORMED: --- -- Range Section <br /> NEW WELL/BORING(CPT GEOPROSE MYDROPUNCp(,pgNO-AUGER,OTHER-)El SOIL BORING# -I , g•t' �•J B,y @CS ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑WELL# ElOVER-BOREDIAMETER <br /> El"OTHER ❑PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> ------------- <br /> SPE---OF WELL INSTALLATION TYPE <br /> ❑MONITORING CONSTRUCTION SPECIFn <br /> ICen <br /> ❑HOLLOW STEM DW.OF BOREHOLEZ rr <br /> ❑EXTRACTION ❑MULTIPLE CASINGS[]MULTI-LEVEL WELL CASING DIA: <br /> ❑AIR HAMMER/DRIVEN CASING THICKNESS �� -- <br /> ❑VAPOR ElMUD ROTARY TYPE OF CASING:11 STEEL (3 PVC ❑ OTHER <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CP —� <br /> T)_GROUT SEAL PUMPED:❑Yes I?No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ®SOIL BORING ®HAND AUGER GROUT SPECIFICATIONS &rc yr 510 <br /> ❑OTHER: `! b4C.r<Fr I1 <br /> ❑OTHER: APPROX BORING DEPTH (p -` I C <br /> COMMENTS: CONDUCTOR CASING PROPOSED 11 BOLTED TRAFFIC BOX OR ❑ <br /> V YES,li9.per K ams m m,e,,,..STSTOVE PIPE <br /> NOTIL OFFSITE BORINS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 ORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify th t I have red this plication and that the work will be done 1 accordance with San Joaquin County Or nances,Rules an <br /> Regulations,a Il ap c CalifornI Laws. <br /> Signed <br /> Tille/C <br /> Print Name I 7 CC <br /> Date <br /> DEPARTMENT USE ONLY pig <br /> SITE MAP IN UNIT IV FILE,ADDRESS: � <br /> WORK PLAN DATED: RIO <br /> APPLICATION ACCEP <br /> GROUT INSPECTION BY .8,( DATE ISSUE �7 AREA C� <br /> G /g 0 DATE /T 0 <br /> DESTRUCTION INSPECTION BY FINAL INSPECTION BY <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE I FO FAC# <br /> N AMT REMITTED CHECK# <br /> ppy RECV'D BY DA <br /> VA- <br /> TE J� PERMITISERVICE# INVOICE <br /> C-57 �O WC WA !3 r0 i /7 _ / SR# D <br /> EHD n.oI 11r 7(WE9) U57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> ENCROACHMENT DOC <br /> WELLPERMITAPP <br />