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,oag co SAN JOAQUIN COUNTY FILE COPY <br /> ENv,RONMENTAL HEALTH DEPARTIVir-NT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> r ._a\P Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s a: �E��/�C IT IV <br /> WELL PERMIT APPLICATION Co 77 <br /> JUL 2 9 2009 RSI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENViRRN1�:1EN r HEALT�, <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apF'+� ade to cpWp lance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health 10474 <br /> �� I A Assessor's <br /> Well Location._�/]/� _O _F Cross Street i (CmYdr;,A City r-Cl Zip l Parcel# a35"15'a9 <br /> Property r� _ <br /> Owner '5� � 'C.IC� Address . oy�',r1V�L [0,'✓t�—N��4�x� City Zipy5 6 Phone#o��g-�'3I"-�C�/5:� <br /> C-57 Contractor 1� Address .A:W/��v�� ,�::L/, 4 r City � Lic#90, 33j Phone 20-(,az L2q � <br /> Consultant/Sub Cntr )k . � Address OP1 l V�Yn4r Gf. City 06-k j6l )c� Lic#.(fN4V Phone`Jld-&r3-///00 <br /> GIS Coordinates:X 57. 7,31 ,Y J;4L, lfo�4 Township Range Ea 0,+ Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCHrrH�AND-AUGER,OTHER') �5/ ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> �SOIL BORING# �r -7C,V�. ❑ OVER-BORE DIAMETER <br /> ❑WELL# / 5✓�' S/ [:1 PRESSURE GROUT <br /> ❑"OTHER `` 7'��(/� ,/ GROUT SPECIFICATIONS <br /> COMMENTS: �� F`-)c Y,',v�S S t- 7 C • <br /> 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS SS <br /> ❑ MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ti ?7j ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: C <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑ PVC ❑ OTHER 0 <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑qf HOSE <br /> � f <br /> ❑AIR SPARGE/OZONE l"+PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 9HAND AUGER GROUT SPECIFICATIONS �'Tom„ t1 ,y-"Li �1 �.L Vrl <br /> El OTHER: El OTHER: APPROX.BORING DEPTH WIVB ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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. L-, c J <br /> Signed Gf�n..�r ,,,� / Title/Company ffpo�l- C2�L061SrZ6AP,6 6eDMA 1/� <br /> Print Name Wf-{ (311W ICBG Date <br /> DEPARTMENT USE ONLY ZIT-�O O <br /> SITE MAP IN UNIT IV FILE,ADDRESS: O i 1 ✓�+�^) <br /> WORK PLAN DATED: V7M&114k G1 <br /> APPLICATION ACCEPTED BY DATE ISSUEQ AREA O <br /> .GROUT INSPECTION BY FINAL INSPECTION BY DATE",,— <br /> DESTRUCTION <br /> ATE ,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 /> o � t 7-z4-tl,9 R# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZAT N SI P E/NNCR//O��ACHMEEE 1T DOC- <br /> EHD 29-01 11/5/07(WEB) �/v! 1�I WEL P MIT APP <br /> a4"-" A—i+ 'V <br />