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LDP CoP VED <br /> �,4�tln SAN JOAQUIN COUNTY FEB 1 :2 2010' <br /> ` ENVIRONMENTAL HEALTH ❑EPARTMEWJOAQUIN COUN <br /> c ^:. NVIRONMEfJTAL `MITE <br /> 600 East Main Street, Stockton,CA 95202-3%Tv' I NmEtTM�nIMITIGATIDN_ <br /> Telephone.(2339)468-3454 Fax:(209)488-3433 Web:ww+n+.s m r lehd UNIT;IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YL6R FROM DATE ISSUED <br /> Applkation 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:Sart <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> Assessafs <br /> VYsil Lowtlon 1805 Harbor St. Cross Street S.Fresno Ave.porty City Stockton 7jp 95203 Parce€ <br /> �r r City of Stockton Address 425 N.EI Dorado St. City Stockton Zip 95202 . Phones(209)937-8212 <br /> C.57 Contractor, PeneCora Drilling Address 1238 Alice Street Suite AC 1Woodiand ZIp.95775 Lic alt 906899 Phone <br /> Consuhannub cntr Huff 8 Huff,Inc. Address 915 Harger Road Suite 33q City Oak Brook,IL'...Dc NIA Phone 630-684-9100 <br /> GIS Coordinates:X Y_ Township 1 North 6 East <br /> -Rangesection. <br /> WORK TO BE PERFORMED: <br /> ©NEW WELLAWMNG(GPT.GEOPROBE,HYDROPUNCH,HAND-AurrzR OTHER-) ni DESTRUCTION(CHOOSE TYPE BELOWI <br /> [3 SOIL BORINGS @ OVER-BORE DIAMETER 8.3" <br /> C1 WELL s ©PRESSVRE GROUT Neat Cement <br /> ®-OTHER GROUT SPECIFICATIONS 94#baa&a1.Caal H2O <br /> 0 EXPLOSIVES_ DETONATING CARD` <br /> COMMENTS:See Attached Los for S ecific We1i Info at'orl (MW--5 i3 <br /> I <br /> TYPE OF WELL MT-ALLAT12N TYPE -co"MUCTION SPE(;IFI6ATIONS. <br />€ Q+ MONITORING C+J HOLLOW STEM CIA.OF SOREHDLE 8.3" 0.MULTIPLE CASINGS Q tdULTW_EVEL WELL CASING DIA:2.D" <br /> Q EXTRACTION ©AIR HAMMER/DRIVEN. CASING THICKNESS 0.154" TYPE OF CASING:Q STEEL 0 PVC Q OTHER <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL" TRWIE TYPE TO BE USED 12 AUGERS-©HOSE <br /> Q AIR SPARGEtOZONE [ PUSH PONT(GP OR CPT)_GROUT SEAL PUMPED:.@ Yea Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 3t]') <br /> r Cl SOIL BORING ©HAND AUGER " GROUT SPECIFICATIONS <br /> i <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH .See Attached I.oW©BOLTED TRAFFIC BOX OR Q STOVE PIPE <br /> QP)zvCCOMMENTS:See Attached L09S for Original Lonsrr`l�ctPg°o`n information '' an <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> i <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 /> I Repuladons,and all Ilcable Ca ala Laws. <br /> Signed "t _TitlelCompany <br /> Print Name = p .^` Date � /t. !, <br /> DEPARTMENT USE ONLY <br /> ,rr _ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: &S <br /> I <br /> WORK PLAN DATED- <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA 07 <br /> GROUT"INSPECTION BY FINAL INSPECTION Y DATE <br /> DESTRUCTION INSPECTION BY DATE Za 117 ' <br /> k COMMENTSlCONDITIONS: ,f <br /> ACCOUNTING ONLY: AID# FAC# ~ <br /> PE CODES I FEEINFO AMT REMITTED CHECK# - RECV'D BY DATE PERmmsERVICE# INVOICE <br /> f 3S•oz �6� Io� I sR#L�S <br /> p C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2301 10128!09 WELL PERMIT APP <br />