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SAN JOAQUIN COUNTY <br /> ? RONMENTAL HEALTH DEPAR11.04 SITE <br /> �� <br /> CaYof <br /> East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> % 09)468-3449 Fax: (209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> NOV 0 5 2009 WELL PERMIT APPLICATION <br /> ENVIRONMENT LICAL1H <br /> PERMI.IIS - FUNDARI E 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 Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's <br /> Well Location 7 3?51g&k 6a.Arli„a R,l,Cross Street �{c+r lei po.. w 0.� City Zip a53 T'1 Parcel# '-1- - <br /> Property ` Zi 9vS10 Phone# (559 <br /> Owner��1,.e11 n:1 57.,,.E Address Z 6t4 5 S.W�4L�n� City P <br /> C-57 Contractor vr,�t' Address �I O City Lic#4851to5Phone (91"5 313-58-W <br /> Consultant/SubCntr 56ky%AxS, Addressloil_V; erc.► S.,t1K. lt� City ,,��.,.:,.��Ic# S ggPhone1R16�$fa1- <br /> GIS Coordinates:X Y Township soh RangeSection 1Q__ <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCT❑OVER-BORE N (CHOOSE <br /> CHO S TYPE BELOW) <br /> 171 SOIL BORING# ,q <br /> ❑WELL# PRESSURE GROUT rAw - 8 atk MW*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: I <br /> a V c. o' ''k <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑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 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 <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑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 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. <br /> Signed Title/Company <br /> Print Name _7aman gown Date 11 z I Z cog <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Z 3X d <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY �( n.►.� rc�n DATE ISSUED 1 t 2`/ O AREA <br /> GROUT INSPECTION BY UL- ce FINAL INSPECTION BY < DATE 1LI07 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTSICONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 3.6-oz- .a 6o.00 21Zt€cz sc cd *ffi-( a SR#S&9g2. <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) WELL PERMIT APP <br />