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a SAN JOAQUIN COUNTY 0 . <br /> ENVIRONMENTAL HEALTH DEPARTMENT- SITE <br /> z <br /> b' < <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> . LL Telephone:(209)468-3454 Fax:(209)468-3433 Web:www,sigov.org/ehd UNIT IV <br /> <rFOM1� <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 /> Assessor's <br /> Well Location 5ArWWt�� Cross Street L.n W`tf\ City &lk- 1Ck-0n ZipIS 03 Parcel# 133- 2, IS <br /> Propertyp0Wfw3 <br /> Owner <br /> Address 6-0 l W.14000f STe,soa City St-oJCtem Zip 'ITA03 Phone#(,109)9.12 -2L Z L <br /> C-57 Contractor 1,TAS Dntk•r,� _ Address q.o Hmic- Q.aZ _ City AWWAOe Zip916V Lic#Nf5'l4,f Phone <br /> Consultant/Sub Cntr Me-4e•C Address 30 IT k•ISO rt- 0 Sit t00_ City (414,j% Lic# Phone of I P1 of <br /> GIS Coordinates:X ,Y -,Township ) tV Range (D t Section to <br /> WORK TO BE PERFORMED: <br /> '?INEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 19 DESTRUCTION(CHOOSE TYPE BELOW) <br /> W SOIL BORING# q O•PG'-Ir ANCA. ❑OVER-BORE DIAMETER <br /> ®WELL# RPRESSURE GROUT Trr M. -! w✓ <br /> [R*OTHER � Q 4 - V V OS'f of &e 4uA. GROUT SPECIFICATIONS <br /> loot•n, ❑EXPLOSIVES DETONATING CARD NCn ,— <br /> COMMENTS: Thwa 1, bor sS- t4:%% 1ia <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �4 <br /> E]MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �l•J [I MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS r TYPE OF CASING:❑STEEL ❑PVC [I OTHER 1.3 P' <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL L n r TREMIE TYPE TO BE USED❑AUGERS R HOSE <br /> 0 <br /> ❑AIR SPARGE/OZONE OPUSH POINT(GP OR CPT)VV GROUT SEAL PUMPED:B Yes ❑No (NOTE:MAXIMUM 11 FFREE-FALL DEPTH IS 30') <br /> 51 SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS � �� K(pwFfa.! cd o�)• 4fwx <br /> I]9 OTHER:CPC -rAVOST MOTHER:c1T-VVasr-Uf APPROX.BORING DEPTH —bo) ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CON WCTOR CASII{G PROPOSED (if YES,list specifications in mmment section) <br /> COMMENTS: S.rVtIS av 6. au4A+wZ �vUda� nW.ow <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,and all a licable lif rola Laws. <br /> Signed 3777 Title/Company f,Q PwaSFcc�•.ly,.teQtK- <br /> Print Name TNA j rancn.E NCM- Date 613110 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A4pRESS: 5COWIrti SNb12L PAIL! Of ^ R=edo r�,�TT I A - <br /> WORK PLAN DATED: SI I lo <br /> APPLICATION ACCEPTED BY I A\ wtiC cr t DATE ISSUED / ' AREA <br /> GROUT INSPECTION BY .ri•. FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICON DITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATEPERMITISERVICE# INVOICE <br /> 2goy' k°I.vo zybbY � B lg to SR# 60836 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2941 10/28/09 WELL PERMIT APP <br />