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o. ,Iry SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPART �-, SITE <br /> Ui CA 95202��!�- (_, ITIGATION <br /> .. 600 East Main Street, Stockton, <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:WWw.siQov.orq/eh UNIT IV <br /> F < t= 0 C T 1 4 2009 <br /> WELL PERMIT APPLICATIO <br /> %VIRUNNILN F NEALTff <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT SERVICES <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. Assessor's <br /> g`�3 E-0E 4� + T 10 I J�`K' l y t"`y L U L <br /> Well Location �� Cross Street Lh�yS���z / X11 e Cit rOC R[0 r1 Zip [ Parcel# 17 efl Z •�7(� <br /> PropeY� r n9�) �0'1+ p SI +k 5+. �OkVI) C Zip J1�1 Phone#M•197. Sl�l <br /> OwnerylN►o�?2��t•� 1�- Address /� v Ino City AA } ? <br /> C-57 Contractor GSC r, I I I Address O , Ia�L �2 City mltr`I'Aci Lic#y$$165 Phone ZS' J13•S��� <br /> Consultant/Sub Cntr <br /> (�QI"PIDISrU.S.,l�ddress 1`10 '2N) S�ttt� ZoD City C�'A�uvr� Lic# Phone.7 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑ NEW WELL/BORING(CPT, EOPROBE,HYDRQqPUyCH HAND-AUGER,OTHER") ❑ OVER BORE DIAMETER <br /> L�SOIL BORING# (s 'Z s �I��oag�+ (s �' S S ❑❑ PRESSURE GROUT <br /> ❑WELL# GROUT SPECIFICATIONS <br /> [I*OTHER <br /> COMMENTS: <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 /> El AIR SPARGE/OZONE PUSH POINT(®OR CPT) GROUT SEAL PUMPED:F1Yes [INo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> e SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: APPROX.BORING DEPTH log <br /> ❑BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> El OTHER: ❑ CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I hav p pared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, Jtp l I le Ca ifio nia Laws. !Q 'D W d— 1 eS} yl <br /> Signed ( �C ' L Title/Company V �J f� I r <br /> Print Name sw�Y 1 er DateZr- <br /> I v <br /> DEPARTMENT USE ONLY ( 1 <br /> SITE MAP IN UNIT IV FI/LE,AD RES�� <br /> WORK PLAN DATED: /b 0 <br /> / I DATE ISSUED 16 1q O AREAgV <br /> APPLICATION ACCEPTED BY <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE�O Z� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS:a `�� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 02,4.of V9° gqai Cc 6 Ce 1611-7-161 SR#0�-'95bo <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 11/5/07(WEB) <br />