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UI . SAN JOAQUIN COUNTY l! II�CM V ED <br /> $ ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 JAN 13 2010 <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.si MITIGATION <br /> SENT HEAI1iT IV <br /> WELL PERMIT APPLICATION PERMITISERVIC� <br /> NON-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 Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 140 Lathrop Assessor's <br /> Well Location p Road Cross Street South Harlan Road City Lathrop Zip 95330 Parcel# 196-110-07 <br /> Property Mr. Faquixyan <br /> Owner Address 5248 Winding way City Vacaville Zip 95688 phone# 760-219-0111 <br /> C57 Contractor Enprobe Address 105 Loma Vista Dr City Orville Lic#7770077Phone 530-589-2019 <br /> Consultant/Sub Cntr Partner E&S Address1990 Grand Avenue, #100 City El Segundo Lic# Phone 415-962-4755 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELLIBORING(CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> [3 SOIL BORING# Nine + 4 Temp wells ❑OVER-BORE DIAMETER <br /> ❑WELL# []PRESSURE GROUT <br /> []*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE'.75 in0 MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS NA TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL NA TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE [Z PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [3 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: 0 OTHER: APPROX.BORING DEPTH 15 feet ❑BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (it YES.list snecilwfions in mmment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING OURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I have prepared this applicat n a d hat the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable a Laws. <br /> Signed Kerran Pender ,D Title/Company Partner Engineering and Science <br /> Print Name C nc, ` Date January 5, 2010 <br /> // DEPARTMENT US ONLY <br /> 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (!D Lw"�1 � Pte-- ��7'- 3 YS <br /> WORK PLAN DATED: C- 201 O <br /> APPLICATION ACC D BYAU-SI&f.9DATE I SUED / / &V AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DAT u t <br /> DESTRUCTION INSPECTION BY 1 ` /DATE / _¢ -/ f� <br /> COMMENTS/CONDITIONS: SSA "�2.1� -41 �� AnJ -e A-^'�"i` r^^'r-�^� Ate!-tSw.l�►.+ OL 9. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMR/SERVICE# I INVOICE <br /> A9.01 ' ffI7 - I YS'12 14r I! / o I SR#Nr-7/7 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 24-01 1115X7(WEB) WELL PERMIT APP <br />