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SAN JOAQUIN COUNTY <br /> „4, ��vi � U ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ll L 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www sioov ora/ehd <br /> 2009 UNIT IV <br /> F° JUN 1 1 <br /> ENVIR0114ENT HEALTFI WELL PERMIT APPLICATION <br /> PERN',iT/SERVICERJON-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 /> Well Location 3`166 N• Q2h��Cross Street W- EvCt,D Ave, Assessor's <br /> Property city S-oGk zip gq9$zo4 Parcel# 1 u-1/o •�!2•S <br /> Owner REI�b �1n dress ZZI Tuxeoo 1_T. '*A City S'40a rpA Zip ! 24 Phone# <br /> ,-.��U.ul" yl SGdLe — P�• y6 ` Oa -233 <br /> C-57 Contractor — Atltlress City Lic# Phone <br /> ConsultanVSubCntr KLBNFr:LOER. Address 2CX51 ARCK-AM o-a- "WC. S�CT.k <br /> h Lic# `•1677fZPhone Zc9. 9416. 13YS <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> IK NEW WELL/BORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> JR SOIL BORING#-11 $-Z/ 3•J, $•4 (3.f ❑OVER-BORE DIAMETER <br /> I]WELL# ❑PRESSURE GROUT <br /> El`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING t]HOLLOW STEM DIA.OF BOREHOLE Z' <br /> ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER _ <br /> Cl VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED I-]AUGERS[j 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 C7TWT SIU <br /> �`'I diAtlt Fi 11 <br /> ❑OTHER: ❑OTHER: <br /> APPROX.BORING DEPTH 6 IS ❑BOLTED TRAFFIC BOX OR ElSTOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PftOPoSEO (HYFS,lisl sperym(ions inommment setlion) <br /> Ath <br /> gredthis <br /> REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> RKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I herebytion and that the work will be done I accordance with San Joaquin County Or nances,Rules andRegulat / C„Signed Title/Company ' //tPrint Na <br /> Dale <br /> 'I >-rDEPARTMENT USE ONLY PE, OQ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `t > )l N• ayy�� S'tB � �LS�rn _ /JD <br /> WORK PLAN DATED: .[/ ! 9Ll R <br /> APPLICATION ACCEP BY <br /> DATE ISSUED1111111 <br /> �7 AREA <br /> GROUT INSPECTION BY N FINAL INSPECTION BY JAG <br /> DATE _ I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: — 4a (y 6 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE I / <br /> J?of 81 - F9- t3 /� i-y� �� �jjSpEERjMTSERVICE# <br /> t <br /> C-57_WC .WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EH0 2941 111907(MB) <br /> W LLPERMiTAPP <br />