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,o SAN JOAQUIN COUNTY FILE COPY <br /> .. ................ <br /> ENVIRONMENTAL HEALTH DEPARTMEN SITE <br /> CA 95202-302 o I��' (� <br /> 600 East Main Street, Stockton, LI IGATION <br /> P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sjNIT IV <br /> WELL PERMIT APPLICATION JUL 42 9 E009 <br /> � 4 KIENT HEA!TH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISr <br /> AT/SERVICES <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. t3S /Sa-7" <br /> { pp Assessor's ?i 1r•/50• 1 <br /> Well Location L' �YGtr:c f U lam( Cross Street C�ENv 'L_ City p r <br /> ct. Zig Parcel#a3,5 <br /> . %. -�L e <br /> Property II 11 (� u{yam I690 _ 3� <br /> Owner l� C 1 Address 1-7 ur.T)C`,U,o CkS'. fit, City 011,) j (�o zip(4/9mhone# <br /> C-57 Contractor (iYec (fl\ck Address `cy,! • City i C ( Et;�Q Lic#*X65 Phone <br /> C <br /> Consultant/Sub Cntr �►11[� r-'st'la Address��ll q � y-4_12 I kCity 0( Lic#-. Phone <br /> GIS Coordinates:X /•731 'Y _/a1, 446 ,Township a 2)Ar'R RangeE iEi�.St Section ZCg <br /> 'RK TO BE PERFORMED: <br /> NEW ELL/BORING(CPT,GEOP�RIOBE,HROPUNCH,HAND-AUGER,OTHER') F1DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# 7 G / Ci �j�• 3 ` I� ❑ OVER-BORE DIAMETER <br /> WELL# ❑ PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS°/S:7�r Q,315-*-15 cy.���/5-;a S Dry 1-tq el t ,r,, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE " rf ❑MULTIPLE CASINGS❑ MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR UT <br /> GROUT SEAL PUMPED:❑Yes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> �I SOIL BORING WAND AUGER GROUT SPECIFICATIONS 44 <br /> El OTHER: ❑OTHER: APPROX.BORING DEPTH Ilia qVt ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSE (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 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,and II applicable California Laws. �, <br /> Signed con c Title/Company r{�as C(�T_ (,5MV 6!IST /,W AC 67R1'{/I�121x <br /> Print Name _ MA12-t C-i l UMoa C-7 Date <br /> DEPARTMENT USE ONLY 6D <br /> SITE MAP IN UNIT IV FILE,ADDRESS: p Cd 0 .CV <br /> WORK PLAN DATED: *3 <br /> APPLICATION ACCEPTED BY DAC An"a" r famw AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> I <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 2`fo # <br /> C-57WC vor -WAIVER C57 LETTER OF AUTHORIZATION T SP MI NT DO _ <br /> EHD 29-01 11/5/07('✓cEB) { g ( _•, <br /> 7 WELL P MIT APP <br />