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j opq'I" c SAN JOAQUIN COUNTY <br /> _' E <br /> ;,tip NVIRONMENTAL HEALTH DEPARTIV eI T SITE <br /> 0: X <br /> 0 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> .• -. •P p i i 09) 468-3449 Fax: (209) 468-3433 Web:www.s6gov.org/ehd UNIT IV <br /> ECP <br /> U vv <br /> 1111 �u SEP 3 0 2009 WELL PERMIT APPLICATION <br /> G {�MEN.AJ� IONtil��EUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby Fn� -jr <br /> lY��i-`�ty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Develop t ap er 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> �j �]- p�_ "� +-Assessor's <br /> Well Location " 'obT WI I ((• Cross Street L�(� KDOL � City 1 raCY Zip Q 5z371�O Parcel# Z I Z•bl(L'•I 1 <br /> Property//�� /� 3 l Phone# <br /> Owner 1.4 11 at- \\ Address ?4 kat( lly d^ City "QCZip `7 5�/�7,� �,I�J�I yy�D <br /> C-57 Contractor tr,I 166 �`-YT•Address 2310J5 I q wam Dl• City Lic#rcP�lPhone 209 z1�y5 U`ll <br /> Consultant/SubCntr tY< V1folriUllW�Address�395-(f ill tfia YC•City ra Lic#65156) Phone <br /> tic, �3�j b-7 54 <br /> viG�S, tic, <br /> GIS Coordinates:X Y Township Range Section <br /> W RK TO BE PERFORMED: <br /> NEW ELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> ;gWOIL BORING# ❑OVER-BORE DIAMETER <br /> LL# PRESSURE GROUT <br /> Lj*OTHER GROUT SPECIFICATIONS /� <br /> COMMENTS: Tkt'5 oc/l will Apt r c� iegr {wt%n ccrl - « e eJ'c <br /> Ad&Coed uso.kD/G.1 �G e 200 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> AONITORING U�-fZLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:�C " <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS .Sck 90 TYPE OF CASING:❑STEEL Iff PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 7-6-6 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR P Ik.I <br /> RO S El Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> El SOIL BORING ❑HAND AUGER GRO S 4IFICRTIONS /yf47- Ce/y16A1T <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH 20 El BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> 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 1 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations, d I applicab Califor is Laws. <br /> Signed 11 n Title/Company Pces�dex,� rVYlgfli L�+IY)(p(Irnt � ,VICCS,IY1(. <br /> Print Nam _YIn �1 naj--, Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3q D 0 401 I., 1X1 I <br /> WORK PLAN DATED: V0 A -2.-0© r�_ <br /> APPLICATION ACCEPTED BYi DATE ISSUED a k.d4EA <br /> GROUT INSPECTION BY _ _�/��slMp�A_i 1011�/0� FINAL INSPECTION BY 1,4S41A ,�g, DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 33 �r 7 SR#,jg 39 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />