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UI <br /> SAN JOAQUIN COUNTY aur 1 9 2009. <br /> a ENVIRONMENTAL HEALTH DEPARTRffiN�,1F T HERS- <br /> . .� SITE <br /> 600 East Main Street, Stockton,CA 95202-3 MIT/SERVICES MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sj oq_v.or /q ehd UNIT IV <br /> 3 <br /> srF � i <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s <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 W, 1),4, <br /> chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> WellLocatiioon����W, [JT. CrossStm t (j�-&5man Assessorso`•� City 1�G�Zip L?� /Parrelry2SO-/t1D1c'1J- / 3 <br /> OwProner T von nL h,IIZ(— Address U 0 6151, city I� 1 Zip I1(Phonefl D � 744 1 <br /> C-67 Contractor S "Dr- Address 2-2.0 /V.F4 S* �, Ci k;b ic,-�of Lic# � hone S-3c,-009%0- !zv <br /> Consultant/Sub Cntr&rG ASSL',G It. Address 07 LO,,j &1.—Aye 5kZO/City h aYP StL0 Lic# Phone <br /> GIS Coordinates:X Y Township + Range S"6 Section es <br /> WORK TO BE PERFORMED: ; <br /> JONEW WELUBORING(CPT.GEOPROBE,HYDROPUNCH,HAND AUGER,OTHE)r) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# D OVER-BORE DIAMETER <br /> 2*ELL# ylgA�- ❑PRESSURE GROUT <br /> [I*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 9-lrAONrroRiNr3 FOLLOW STEM 01A,OF BOREHOLE tjjj: 0 MULTIPLE CASINGS 0 MULTI-LEVEL 'WELL CASING DIA��� <br /> [EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS tJ ,Sc�rLd TYPE OF CASING:❑STEEL p.VC El OTHER {� <br /> 0 VAPOR 0 LAUD ROTARY DEPTH OF GROUT SEAL -3 TREMIE TYPETO BE USED 0 AUGERS O HOSE I <br /> 21(IR SPARGEfOZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes M o ({VOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [3 SOIL BORING I-]HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: ©OTHER: APPROX.BORING DEPTH Z J Ft: 9�-315LTED TRAFFICBOXOR 13 STOVEPIPE <br /> ) ] CONDUCTOR CASING PROPOSED (if YES,list specirmw ns in=mnent section) <br /> 1 <br /> COMMENTS: ©c—!L n 1A f:) C�.��• -1 1 (� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS y <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and altaplicable C titoml WS. <br /> Signed Tidle/Com pang <br /> c r � <br /> Print Name J cl Jd) ,A_ Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 7r!7S w ,(l Sze . '7.�.c�► <br /> WORK PLAN DATED: zfte/oJ <br /> APPLICATION ACCEPTED BYolGr5fJr1 DATE ISSUED AREA �yS3 <br /> GROUT INSPECTION BY FINAL INSPECTION BY t/ f®/! DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> I <br /> COMMENTS/CONDITIONS: <br /> i <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE alt INVOICE <br /> ( <br /> 979' SR#0051157 <br /> C 57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC 1 <br /> EHD 29-01 116107(WEB) WELL PERMITAPP <br /> i <br /> L <br />