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*flECP'*e909) <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> 468-3449 Fax:(209)468-3433 Web:www siaovOralehd UNIT IV <br /> SEP 3 0 2009 WELL PERMIT APPLICATION <br /> N NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby IWO Y for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County ZD,ewelop per 9 1115.3 and the_Standardss of San Joaquin CountyEnvironmentalHealth Department <br /> J"IQD'' 1 11 7*� LUAt�'r WNGI Cil 1 rQC',y Zip "1 J37IOParcel#rsZIZ"�I(D'I I <br /> Well Location TR1l(1 W 11• Cross Street y /— <br /> Property 1 4Trac.� Address �zoTraC��IVd. Ciry " zip <br /> �2 /� &0431-y'�llc� <br /> �•�r 77 �� ����99,1��l71PP Phone#/ c <br /> C-57 Contractor I Id7111'' YII 1 IPC•Address F3CD5 wag? Dr. City�1tfvLF-+v11— Lic# g -7Phone`2� [IJ871Z <br /> Consultap05ub Cntr Ri VIYOYI �ddress Z39✓CC.. Piro YC•city YG Uc7t65I56) Phone ZD9 833"fl�58 <br /> C�v i CfS.111I tTG. <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO BE PERFORMED: <br /> ANEW L/ <br /> LBORING(CPT,GEOPRORE,HYDROPUNCH,HAND.AUGER,OTHER-) 0 DESTRUCTION(CHOOSE TYPE BELOW) <br /> / ` FIL BORING# 0 OVER-BORE DIAMETER <br /> LL# M W UST- :i 0 PRESSURE GROUT <br /> F01 IL <br /> GROUT SPECIFICATIONS <br /> COMMENTS: T45 N fl w /l Le 1[ r/ <f- <br /> n. .L <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> R ONITORING r/YliGLLOW STEM DIA.OF BOREHOLE 8" ❑MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> S <br /> ❑EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5,Ck 5/0 TYPE OF CASING ❑STEEL 113PVC 0 OTHER <br /> O VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TBD TREMIE TYPE TO BE USED 0 AUGERS O HOSE <br /> 0 AIR SPARGOOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS /VfI Cf A4fAJr <br /> — / / 1 <br /> ❑OTHER. ❑OTHER: CONDUCT BORING PROPOSED CD HOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASINO PROPOSED (AYES,list specrtcmronz in mnmeM frGion) <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 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d I appllcab Callfor la Laws. �n;C ,.I p.,,� t1f�' _ I IT(l� <br /> Signed nn Title/Company \ 'ntu"" '��n�D1�I11(tij'pX•�PX VICCS IIV7[. <br /> Print Nam Date S-3-o9 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE.ADDRESS: <br /> WORK PLAN DATED:_ <br /> APPLICATION ACCEPTED BY IAS - DATE ISSUED,t n ref 101_ —AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: — <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'O BY DATE PERMIT/�s;7�3 <br /> # INVOICE <br /> 35'1711 '(3`/100 Z� 3fr tO ' 09 <br /> C-57WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> WELL PERMIT iPP <br /> EHn 2901 11/5W(WEB) <br />