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eP4ut' SAN JOAQUIN COUNTY <br /> E �Q V C' DD ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> _ 1 2069lephone:(209)468-3454 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �rFORN <br /> ENWRONMENTHEtAfLTH WELL PERMIT APPLICATION <br /> PERMIT/SERVICESNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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/Deevelo�,p(ment Title, <br /> �chapter 99-1115.3 and the <br /> gStandards of San Joaquin County Environmental Health Department. <br /> I 1� W ca�T LfY�'CE VOV!bov� q Assessor's <br /> Well Location/ J ross Street S� - City ps� Tb�Zip ! Z0 Z Parcel# t('f •b Z OPro ' D <br /> P. <br /> Ownerty �l3 11111II E ff .�1I }� 1I Address 34o I cti chi AJ YOA) ,e.�@*%A iV 1Y o Zip 944'53 Phone#I ZSq y l S.6 3} <br /> C-57 Contractor W oc tkW0.✓O 4,111 iq Address _ Aj5iO r-Lv 2v A City Rl0 V 4& Zip 451 Lic# 7(OD7 / PhDn <br /> —�v ?3 <br /> CansultanUSub Cntr STAAT1G C. AddressS'� AF,4 <br /> ( YtT1'E CAA. ,4404. (A•F�4YETfS Lic# Phone 95� 2 <br /> Z91.43oox <br /> fi <br /> GIS Coordinates:X ,Y ,Township Range Section 23 <br /> W RK TO BE PERFORMED- <br /> NE LL/BORING(CPT, ,HVDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SWOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE Cl MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 'SOIL BORING ❑I HAND AUGER GROUT SPECIFICATIONS <br /> `❑`OTHER: _ *THEPo DI'C'E�-�APPROX.BORING DEPTH 15' PE• -r 0 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> F CONDUCTOR CASING PROPOSED (if YES,list speafimtions in mmment section) <br /> COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cartity 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 applicable,California Laws. ( ,,11 '' �`\ �II_- � /� <br /> Signed `le_�.� � Title/Company {`ro3ec, W�?v.cpge2 /sTCkAeL ( LV9 Lj <br /> Print Name -e�V Ii- -`1 Date t 3�1/Oq <br /> (/ -/ DEPARTMENT(USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �`P 7 O GV .( ,i LSMtoeJ <br /> 4i4Oy- o•SO <br /> WORK PLAN DATED, /i/0 <br /> APPLICATION ACCEPTED BY DATE ISSUED M/07 AREAZ <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY f DATE p <br /> COMMENTS/CONDITIONS: Ll <br /> J /� t �3 pZ 9• SD <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 91901 M 85 Z.2&632— 1Z Di I SR# M:RC) <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />