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a4 '" 0 SAN JOAQUIN COUNTY 0 <br /> r.• ` ENVIRONMENTAL HEALTH DEPARTVENT SITE <br /> Q: <br /> 600 East Main Street, Stockton, CA 95202 029 MITIGATION <br /> hd/ <br /> Telephone: (209)468-3454 Fax:(209)468-3433 Web:www.sjgov.orGe <br /> UNIT IV <br /> tIFORN <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,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> pp Assessor's <br /> Well Locationeuo u,WeNw Cross Street L.n Co\n City ` R3 Parcel# o2 <br /> Property . SOS W.uJe.bv lam•S;O• °3 <br /> owner S ok Address Ef D.r.lo S+. City 9.ekhy, zip q$jS'L*�'L Phone#Ciel) 9z'JL- � <br /> W H 9 3a 4x ZAY " 7 r y�2s <br /> C-57 Contractor Address City �I1G� Zip_ Lic Phone <br /> Consultant/Sub Cntr yaFK AddressSE toO City . w Lic# Phone Cl)(, <br /> GIS Coordinates:X ,Y ,Township N Range ('01" Section 10 <br /> WORK TO BE PERFORMED: <br /> ' •(NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# HW E •1 W r-t ❑PRESSURE GROUT <br /> ❑"OTHER GROUT SPECIFICATIONS <br /> ❑EXPLOSIVES DETONATING CARD <br /> COMMENTS: jUdy"X.2" we\IS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> El MONITORING HOLLOW STEM DIA.OF BOREHOLE %�." ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: y rr r <br /> RDEXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS SLF WOTyYrPE OF CASING:❑STEEL IW PVC ❑ OTHER <br /> ❑VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL Q') —1-f I TREMIE TYPE TO BE USED❑AUGERS R HOSE <br /> M Sr. AFF•4.) <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:ij@ Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Nf.F te,ev'V <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH It•S &I BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list sPr sticm in Comment section) <br /> COMMENTS: 0C'%k5 '44rSN e5 4r u 1.. (4`.�+ \`r'u'tti. Ar. +vcs (' All yJ rt)•t-�i(t <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 preps ed this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and:11 applic I alifornia Laws. <br /> Signed <br /> 2 Title/Company -Lt- maiTCtT Me�+hb CyZ <br /> Print Name T]lA✓ .ICNA.C/WOL Date Cljll0 <br /> DEPARTMENT USE, ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: eLr 51 -- <br /> WORK PLAN DATED: A jv\c""Uk"'. 5 I. D <br /> APPLICATION ACCEPTED BY r DATE ISSUED T L rr7 AREA <br /> GROUT INSPECTION BY 8 F O FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICO N DITI ONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 't°1 1 -9 .00 l 1.00 1A 64,4';+ 1 SR# <br /> C-57 WC/ -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT / ENCROACHMENT DOC <br /> EHD 29-01 10/28/09 WELL PERMIT APP <br />