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i <br /> EC8V <br /> OCT Q 2 2009 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> l��A90 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> OVUM <br /> (209)468-3449 Fax:(209)468-3433 Web:yM,siaov.org!ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> ICON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DALE 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 /> ��JJff�� Assossors <br /> Well Location�39L F, M'100 �. Cross Street Yiccolj �� City $fock+oct np`s,g is _ Parcel# WEI- 100z. I <br /> Property <br /> Owner W iligm TQ-c(O f e Address �S l S. �cwq�rf Sl vd ���Ity �3�e�y S Zip A7I NS Phone# <br /> C-67Contractor far , J `rjeHvh T6a—Adress 9150 U210C Ypgp„� City�{� Lic#V 16 Phone <br /> -'v- <br /> e��f2ctir��4vOrS <br /> Consultant/Sub Cntr c�I Address SgoD 116(_IS: St; Sft A City Lic# \ Phone <br /> ssoctrti c.f ” <br /> GIS Coordinates:X Y Township Range_ Section <br /> WORWfLtOORING# <br /> PERFORMED: E <br /> 'N ORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER• O-DE$TRUeTIDN-(CHGGBE-TYPEBELO" <br /> ❑OVER-SORE DIAMETER <br /> }��WELL# M 10_ ❑PRESSURE GROUT <br /> 'L�'OTHER- �((otJ-'Stq _A(,46.er GROUT SPECIFICATIONS _ <br /> L <br /> COMMENTS: 0wr4 e work ac garf j tiAhrtf;ot, of y31S CWdecloo mond Slocklo" <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORINGtOLLOW STEM DIA.OF BOREHOLE I'� 'MULTIPLE CASINGS MULTI LEVEL WELL CASING DIA: I <br /> Q EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS SCS, SID PVC TYPE OF CASING:Q STEEL X'PVC CI-OTHER <br /> O VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 6 rT TREMIE TYPE TO BE USED HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) y�GROUT SEAL PUMPED: Toa CJ No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> O SOIL BORING ❑HAND AUGER GROUT SPECIFICATION'S`Om 1`f'IA41 OfD _ <br /> []OT HER:, O OTHER: APPROX..BORING DEPTH Id BOLTED TRAFFIC BOX OR E]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED �,-, (if YES,list epocifkallone In comrnant section) i <br /> COMMENTS: Screern <br /> I <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> . I � <br /> I hereby certify that I have prep ed this application and that the work will be done I accordance with San Joaquin Count Ordinances,Rules and - <br /> Regulations, p alifor s. <br /> Signed TIUe/Company �VjQ IIr <br /> / I <br /> Print Name i'S. U �V Date i <br /> � . <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �q <br /> 15 1 14 , J3-17 <br /> WORK PLAN DATED: D '4 1 !/ <br /> APPLICATION ACCEPTED BY DATE ISSUED t d S 0 AREA�ZD�j <br /> GROUT INSPECTION BY I_:I�lnn/l[+u� FINAL INSPECTION_BY DATE / <br /> DESTRUCTION INSPECTION 13Y DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY:. AID# FAC <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT(8ERVICE# INVOICE <br /> WC WAIVER. C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DOC <br /> EHD 28th 111115/07W-8) .. WELL PE(Mn APP <br />