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(1 D <br /> SAN JOAQUIN COUNTY <br /> ?, ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> c��\V/ �� 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> P telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> �Li,i=oRi?� <br /> MAR 1. 7 2009 WELL PERMIT APPLICATION <br /> ENVIRONP,IEN, HIEWWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 vo� <br /> fERMil/SERV101 <br /> Application is hery 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 Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> Assessor's <br /> Well Location E.(�rw�r��rc R�. Cross Street bv, City TR,Kj ,CA Zip S 7-6 Parcel# 1S0-'00"O8 <br /> Property t <br /> Owner Address 3 01 Cro.�l Ccr (�C City S`1R4,. Zip_ s _Phone#�� (S- <br /> C-57 Contractor 0� r' Address sSc) P,JY�'20h� cityV i (A Lic#-11W7gPhone 0-1 -1300 <br /> Consultant/Sub Cin G(� on Address �� 'fp 4 glJ S�Cify�c��nti+( 4 Ic# Phon q�{i 3 <br /> GIS Coordinates:X I� STownship 2t Sati� Range r,� Section, �L <br /> AORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE HYDROPUN H, AND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# I ��-Z `L _ ❑ OVER-BORE DIAMETER <br /> WELL# ❑ PRESSURE GROUT <br /> p*OTHER -$ Z X563�3,56 ;,A�-C ��g3.s6k/1��_S6S�A�-sCl, <br /> OUT SPECIFICATIONS (, <br /> COMMENTS: — p� Obi �) �ic !155 <br /> N <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> \� <br /> MONITORING El HOLLOW STEM DIA.OF BOREHOLE 1. El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> VAPOR O) ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/AA�� <br /> ❑PUSH POINT(GP ORCPT)_GROUT SEAL PUMPED:❑IYes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER I J�GROUT SPECIFICATIONS <br /> IkOTHER:6 ( �OTHER: Nk APPROX.BORING DEPTH M ( 1 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CO DUCTO CASING PROPOSED (,YDS,li specifications in comment section) <br /> COMMENTS: GCCa JOt ILUT <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 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 <br /> Regulation nd icable C i rnia L ws. <br /> Signed J all ap Title/Company p ;Qn�; <br /> Print Name �1�vr�, `���[i� Date_ <br /> �y►� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /�--�/2Q C• (7CG��-I�.0-I�-e ��(�.t y <br /> WORK PLAN DATED: 2�Q !� <br /> APPLICATION ACCEPTED BY DATE ISSUED ✓"-! ('-a/ AREA <br /> GROUT INSPECTION BY '0c'6 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 /> o f e z 3-17-6Y #p <br /> C-57 WC so, -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT 411e, ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />