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E SAN JOAQUIN COUNTY LCOPY <br /> ti ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> FEB 2 3 2 010 <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> �4• Telephone: (209)468-3449 Fax: (209)468-3433 Web: <br /> T HEA(_TANIT IV <br /> WELL PERMIT APPLICATION PERMIT/SERVICES <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. '235-15-216 <br /> // � n Q Assessor's Z.5-115-o(. <br /> Well Location (p _ Cross Street e e��Y�X City Zip l5g71p Parcel#'�'15-43 .Is.Q a <br /> Property ��++�� I p L// p <br /> Owner Qvl_ Address 14od�.kS S4, J to 00 City Zi�one#y�2'Sy�/•g <br /> C-57 Contractor ?r C.ov'�. Address 1' 5AItt.� S�,StMt City Lic#U89q Phone 530-(00-13n <br /> Consultant/Sub Cnti Address.21 of�__ �' FZ�+''City Lic#40ft)Phone6�0���3p'y/�jp <br /> GIS Coordinates:X — _ Township 1� Range Section �O <br /> RK TO BE PERFORMED: !"'� '61VU--i,,-' <br /> NEW ELUBORING(CPT, En--- HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ja SOIL BORING# �j�� �avts+ - Zy_7{3 TRy TIZy-�ql ❑OVER-BORE DIAMETER <br /> "❑❑WELL# J ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS 1 <br /> COMMENTS: �l� Ctl�h S G�/ 3 Ir C� �Ot I �C'�/ 1 �_ 'a38-FK Y-78 I _ 1� y $f <br /> ainjy v <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 HAMMER/DRIVEN CASING THICKNESS ^ TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER (\ <br /> ❑VAPOR ❑MUD ROTARYDEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ElAIR SPARGE/OZONE PUSH POINT(�+�t;r(DR CPT)_._ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS 1 lq Q Q zz� 4�`'i inj d CQ,yh, *ct <br /> ✓✓✓✓ ..LL.� <br /> • <br /> C1 OTHER: El OTHER: APPROX.BORING DEPTH -4D S -- ❑BOLTED TRAFFIC BOX OR [ISTOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROPOSE (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby certify t at I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations all ap licabl liforni Laws. ,,Q�.,� <br /> Signed t Title/Company /Q///�C. <br /> Print Name 94'& DeJX C CLs Date A KI C <br /> DEPARTMENT USE ONLY �A <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �7 26a <br /> APPLICATION ACCEPTED BY QAAREA <br /> GROUT INSPECTION BY FINAL INSPECTIONDATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 7* <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERMIT ENCROACHMENT DOCZ-F-/-4 <br /> EHD 29-01 11/5/07(WEB) <br /> WELL PERMIT APP <br />