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oPa"i SAN JOAQUIN COUNTY <br /> 2' 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE <br /> { 0 East Main Street, Stockton, CA 95202-3029wMITIGATION <br /> `p > ECii�BY IP09)468-3449 Fax:(209)468-3433 Web:ww.sigov.org/ehd UNIT IV <br /> <1 F p [�� <br /> SEp 3 0 2009 WELL PERMIT APPLICATION <br /> y pjN4£Nni �NDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby A��4�y for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Dyevelop per 1115.3 and the�St-andard�sio�f_Saan Joaquin County Environmental Health Department. <br /> X91.0 I� L )a KUt� Cit ir�1C zip1537�OParcel#AssessorsZ12-bhp III <br /> Well Location � �r• Cross Street y Y <br /> Property I <br /> Owner b -1(a� Address 2207��II V d• City '/,_Q Zip �7tP phone#/ 3� yq�DD <br /> C-57 Contractor f i67t ; Inc•Address Z3IP5 Loam br• City 3CDC,C�tm Lic# tL Phone(222? <br /> C-57 <br /> ConsultanUSub Cntr[ 1441 hVI'rOM �ddressz34J�,•PC tro YC•Clty r0. Lic.661l56) Phone M 835-D?58 <br /> •r �. ' v f GCS, TIC. <br /> GIS Coordinates:X Y Township Range Section <br /> )W RK TO BE PERFORMED: <br /> N LLIBORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ////���, OIL BORING# 0 OVER-BORE DIAMETER <br /> LL# M W, UST- ❑PRESSURE GROUT <br /> 'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Fk 5 WelI will )e fon-c r�ile� /iCc! / hatin3 �vtR!/m S 8—� Se— <br /> ADA,lord W o. e-da-t 7-0 0'7 <br /> 1 i <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> L�SMONITORING W Ff1JLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> � I <br /> ElEXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Seo 9A TYPE OF CASING ElSTEEL ZfPVC [jOTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 766 TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_____GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS _ /U,fifT (:E_M4A)r <br /> ❑OTHER. ❑OTHER: APPROX.BORING DEPTH -210 ' iff BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specirc liens in comment section) l <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,and all appllcab Callfor is Laws. <br /> Signed TitlelCompany IReSid viconhnOAJ,�VICCSjY�(. <br /> Print Nam ki) y 10Ok Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3 9 D C9 I+o I <br /> WORK PLAN DATED: VYl a'y <br /> APPLICATION ACCEPTED BY DATE ISSUED O 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'D BY DATE PERMIT/SERVICE# INVOICE <br /> 35'03 ` 7.1,C>o Z� 3Fi' to r 07 SR#fig 3g <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ✓ ENCROACHMENT DOC <br /> EHo 29-at 1115107(WEB) WELL PERMIT APP <br />