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03-12-09; 12:01 PM; ;916 679 2422 # 2/ 3 <br /> >Q e� "•rD SAN JOAQUIN COUNTY <br /> K ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> .� Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sjaov.orG/ehd UNIT IV <br /> LiFbPa <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 wi/h San <br /> Joaquin County DevQQlopment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 0%,MMA 19L-oA^22 a wt-2 <br /> Cc=IpIvOKWO-Y Wc:+r*vo&4i AVe qy 330 assessors t� <br /> Well Location PIVI&V&06( Or Cross Sbeet Plrrcvt9;F s city La•W mp zip Parcel# 196-OSS-� -1` <br /> Property �u� <br /> Ownerst'- NhT1/�1.✓Up Address.n30q'`('O^WY)GC�7P.,h�{CY Dv city rt^�I���,fL✓�' Zip 5330 Phone*/, -��'I '7�D <br /> .0-57 Contractor �� V I'i l�l Address g6000W64M City./'lak�VU-Z Lic# Slwhone -T 25-313-�0O <br /> ConsultanVSub Cnh (/R5 Address 1870�eU¢cY 00 pr City •+YtGr^•(-�Lic# Phone Rl(o-b741-y313 <br /> 11298 i•8 b33 75- 4.4? <br /> GIS Coordinates:X T ,Y 63z 7cZg- �I� township Range Section <br /> KNW RK TO BE PERFORMED: <br /> EW WELLBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-ANGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> KNEW <br /> [I SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# MW M _ El PRESSURE GROUT <br /> [I*OTHER GROUT SPECIFICATIONS <br /> $GYSG0.1 h�ia. <br /> COMMENTS:AWS3713 65-755']MW631G 125^195'1 MW537cD I bS-175r)McJ58313 <br /> Is-75�M W53Zt120-130 <br /> MWEA- 145-1557' 0' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 6 Cv$'❑MULTIPLE CASINGS 0 MULTI-LEVEL <br /> [[[ WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS_TYPE OF CASING:❑STEEL IyJ PVC 0 OTHER <br /> 0 VAPOR XMUD ROTARY DEPTH OF GROUT SEAL�-2.5 bq5 TREMIE TYPE TO BE USED,`AUCE�CHOSE <br /> 0 AIR SPARGEfOZONE 0 PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:'MI Yes 0 No (NOTE:/MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ��''' G'�tTtA'G✓�T"W t �Cl Wl"I-C- <br /> Y1CAY lm.l.{OM i <br /> 0 OTHER: El OTHER: APPROX.BORING DEPTH S OLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,list SPrCAM9o139 n WMM$nt 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,q _ ap Ilca alifo))r�nni��a aws. / U&J� <br /> Signed /,, �VYT. Title/Company 21-0 vr" ` `^' <br /> Print Name CGI all Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:' lQZ—j <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE <br /> ISSUED <br /> - ' O 0 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY t'3 DATE16 07 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: A"AJ 47 AD L. -Sf <br /> 12 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# I INVOICE <br /> �- Ce SR# o -U <br /> C57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHDI9-01 11113/0(WEe) WELL PERMIT APP <br />