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~ • • FILE COPY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street,Stockton, CA 95202-3029 0 �2r j1�j� ATION Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' YjC,( 1/ \. a IT IV WELL PERMIT APPLICATION JUhJ 2 4 2009 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 11;5kpLi1��&,Op�IVTi;./1pEi�lT LIPALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This 9pp&1# 'l/'a5fiWhRE&pliance with San Joaquin County Development Title-chapter 9_1115.3 and the Standards of San Joaquin County Environmental Health Department. A /ZD N• AlZhe� Assessors Well Location.erty — .oss Slreet 7kc_, -,- -., ' L ..-. _. ._� Zip 52D Parcel# /J�2-!b L Owner Addre§s F, Bo d 2,61olo City y1. Zip 2D Phone# 20q-q�R— 56,Z) C-57Contractor WDC- Explor ior�Addreesss 1461 M�vt. � city .04ynyn(L Lic#28 P one 3/6-236-4282- cc�� _ n 9,, . ��,p r^ Q Consultant/Sub Cntr7PiE Consul�,Tddress 2�5 D�' Rd tillk cityl..ly1N1 I14L Lic# Phone 2 -Vp1'-7�O GIS Coordinates:X0 �7'7-% ,. - Y -PaIJ L5-(. Township SID I(7t9 Range Section WORK TO BE PERF RMED" M-9- W I'M lh N 37 5 740.5 W 121 IT -3-4 NEW WELLIBORING(CPT GEOPROBE,HYD OP4!NCH,}IAN0.AUGER,OTHER') El DESTRUCTION(CHOOSE TYPE BELOW) I@ SOIL BORING# -� 7FIYoRr�j IS- jQ ❑OVER-BORE DIAMETER ❑WELL# ❑PRESSURE GROUT ❑*OTHER GROUT SPECIFICATIONS COMMENTS: �l TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE ❑AIR SPARGE/OZONE P(PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 307 tZ SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 0 OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE l� IIYY /� ( 111DUCT0RCASI GPROPOSED (A list spedfimtlonsmmTment vection) ! COMMENTS: Dll"P f [4Y) CTQO�✓OF�e 67 Ijill •eu2 at a NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS �l 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and all app' ble Cali la L p ^� Signed T -o��Ille/Company11C Prim Name L�I ��yf��yj Date 6 i1ai ,Dr �7 ,EPARTMENT USE ONLY / p SITE MAP IN UNIT IV FILE,ADDRESS: r Ly /V, - WORK PLAN DATED: L� 9 APPLICATION ACCEPTED BY DATE ISSUED "Z -O AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTSICON DITIONS: ACCOUNTING ONLY: AID* FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE It/- SR#2 o C-57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHDtaa, ,,�Por(rEa) FILE COEPTY