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1��zCiEIII\?L�0 <br /> SAN JOAQUIN COUNTY ar'AR 0 6 2009 <br /> ENVIRONMENTAL HEALTH DEPARTMENT `';{ �, (p�1 SITE <br /> 1, J 600 East Main Street, Stockton, CA 95202-30291;,-nn s, ,c_ MITIGATION <br /> w. <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:wwsigov.ora/ehc�.VICt,-, UNIT IV <br /> WELL PERMIT APPLICATION <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,chapter1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> II 1), ,! Assessor's <br /> Well Location/3750 N. (a Karel Cross Street rTr^'� I Z. City tnOCn Zip6L4jZParcel# OS —0 <br /> Property <br /> A-C, ►-w A t Address 10100 `Trl'✓O!, i9kw,4 city sftx.k -� A Zip�1-1 Phone#amt-4 79--ZZ19-o <br /> C-57 Contractor lye, a AndarJ4n Address goZ A441+ri1, City L-0J, Lic#64A0LgPhone,2-0-i-5,b7 <br /> Consultant/Sub Cntrk 1Piri�y Ider Address 200( f1Qk—F4 gLof-t- a4-1 . City S'tc c-'O--i-,c-"Uc# *2_42-Phone <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑'OTHERT2 !0 466� r GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 9HOLLOW STEM DIA.OF BOREHOLE'❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL xPVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 5 TREMIE TYPE TO BE USED*UGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes A No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING Cl HAND AUGER GROUT SPECIFICATIONS -1Ale(,+ �O.tinp� <br /> OTHER:P!'e-7QV%41L� V APPROX.BORING DEPTH ,ti �r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (R YES.Gst speoftations m comment section) <br /> COMMENTS: . <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 /> Regulations,an/ all applicable Laws. <br /> Signed /� G ,, , _ _ TitWCompany ?te' <br /> Print Name TT�fI f/������� r`�1, �i– --- [)are���i 4r <br /> S <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> ff k + <br /> w WORK PLAN DATED: <br /> APPUCA 1 i GN ACCEP T ED BY ri1Ui l iii..✓ -A.= of�- I .AREA <br /> GROUT INSPECTION BY FINAL INSPECT 10111 3Y DATE ZL741p� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: I AID 4 I FAC 4 9. <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE <br /> C-57 WC 9 -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT = ENCROACHMENT DOC <br /> EHO 29-01 11/5107(WEB) WELL PERMIT APP <br />