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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> t� � 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> U Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sj.qov.org/ehd UNIT IV <br /> JUL 0 1 2008 WELL PERMIT APPLICATION <br /> [-NVIR01�11EINT HEALTI'J NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r ((�` <br /> Applicat°to�nrAl � a'&U 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 /> ,�.ff // /' Assessor's <br /> Well Location /LTi L3 Jo�'i�[C�i[- Cross Street has"T %' C Cityy� 4-- DLI Zip 9��i Parcel# 141-070-09 <br /> Property , / <br /> Owner �f -s /7;LS7j j b AddressZDf,S- a '/ City FV�S � Zip q�� Phone# R-49-ZZ13'?3/7 <br /> C-57 Contractor 65 D�,-i j. Address 2s�7�j70�Le7E�'/J�JOLCiJ� City 1 ,n~ ille-Z ZipLic# /lS Phone _ <br /> Consultant/Sub Cntr co" z kd ress 16� .C.Y�G(v 1 92S=3 j9 ',F <br /> d^ � City �AhGI�Olro<GloUg Lic# Phone 9/,� `�'.SZ- 9l/�' <br /> s,7t,c I / <br /> GIS Coordinates:X -f2/. 2s72174 Y 39.9.42' 7 To nship //cam Range 7 Section 3y 1 <br /> WORK TO BE PERFORMED: -. `� <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ,®'DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> Jg WELL# A4&1-/ A/ /S ASSURE GROUT <br /> j OTHER elf'-- GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> J MONITORING HOLLOW STEM DIA.OF BOREHOLE 8" uu❑MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Se,4 O TYPE OF CASING:❑STEEL g PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL JA TREMIE TYPE TO BE USED❑AUGERSAHOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:AYes `❑'No (NOTE: MAXIMYM FREE-FALL DEPTH IS t 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS �,(�LIL 2V/. QPt,. a - <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH GL/ 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 /> 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 II gppl' able California Laws. <br /> Signed ` Title/Company C G t GC <br /> Print Name Date _ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 160? f rA 54,1 -.r,+ <br /> WORK PLAN DATED: Z-bs- <br /> APPLICATION ACCEPTED BY �es,�r�L��r DATE ISSUED O AREA_ <br /> GROUT INSPECTION BY � �nc,�� C I (p� FINAL INSPECTION BY M(�iXtiLt.�G�� DATE <br /> Id <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 /> 3Svrj ts� t 0 2313 Vt) I lij 0$ SR# S � <br /> C-57 WC -WAIVERC57C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> 3,503 <br /> EHD29-01 11/B/07 IVZ-fes 1��Od WELL PERMIT APP <br />