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STANTEC LAF 10002 <br /> 10/31/0.8 FRI 10:30 FAX 9252999303 zuuzruuZ <br /> 1,0/30/2008 THU 13: 19 FAX 20943433 SSC EHD 16 <br /> s;ry SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEATH DEPARTMENT SITE <br /> :. . <br /> ?" 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> -) ,.... UNIT IV <br /> �rL��1�11� �Ie hone:(209)468-3449 Fax:(209)468-3433 Web:vrww sigov.Ora/ehd <br /> s 1 L 1 J I[---,,#►4t <br /> WELL PERMIT APPLICATION <br /> OCI 2 8 2000 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ENVIRONW-Al' ��E .Application l`6 �+j�d�l� y[+�. o uln County for a permit to construct and/or install the work described. This application is made in compliance with an <br /> Joaquin Colrt�dliiPmef1� ter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> • Assessor's Q <br /> � 0 �' t I ,Q n(� Zi Sao Parcel# <br /> Well Locatio ss Street �IN�E City � P <br /> (� �/L f� p Zip Phone# 7 / <br /> Property OSS/�/9� 21 7 f7 IA���ritl J -=City V 1Ca � � SBOO <br /> Owner fg�l-L S Address <br /> ( l�rn _ City� Li.# G.Bhone <br /> C-57 Contractor��tr(f nQ(..61 Address f� <br /> 10 <br /> ConsultantlSub Cntr G Address_ <br /> 2 C i�3'E7> Z F1,GIty LicPhone <br /> # 9l�'z99 9�0� <br /> .STownship � Range' ,�Section <br /> GIS Coordinates:X37'�/�?��5 ,Y -1?-[_3214Y-6 , <br /> WQRK TO BE PERFORMED: ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> NEW WELUBORING(CPT,GEOPROBE,HVDROPUNCH,HAND-AUGER,OTHER) CD OVER-BORE DIAMETER <br /> ❑SOIL BORING# 0 PRESSURE GROUT <br /> 'WELL# _A_=� GROUT SPECIFICATIONS <br /> 'OTHER <br /> COMMENTS: <br /> TYPE OP WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS +� <br /> �./ fI MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> pp HOLLOW STEM DIA.OF BOREHOLE �__._.. ❑ <br /> MONITORING (, rf <br /> �j TYPE OF CASING:❑STEEL Fd'PVC ❑ OTHER <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS._(/,_l,!`1 -- r`' <br /> ` <br /> DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED C3 AUGERS D HOSE ..� <br /> ❑VAPOR ❑MUD ROTARY r t3 <br /> eL <br /> ❑AIR SPARGElOZONE E3 PUSH POINT(GP OR CPT)-.....,,._GROUT SEAL PUMPED: Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER_-- GROUT SPECIFICATIONS -C � <br /> APPROX.BORING DEPTH y BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> -•-• (if YES,list sm rlcdflcalions in mmmasoclioll) <br /> C3 OTHER ---._____....._.__.. ❑OTHER: CONDUCTOR CASING PROPOSED ^` <br /> COMMENTS: <br /> NOTE: OFFSITE BORISS <br /> NGS G K NG NIRS NOTICE EQURED ORTINOSp ENCROACHMENT PERMITS <br /> WOR <br /> ccMf NS <br /> that I have prep red this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> I hereby y <br /> Regulations,and ioplvolicatte vallfornia Laws. <br /> T <br /> ___ Title/Company <br /> Signed J Date� t/ <br /> Print Name <br /> f DEPARTMENT US�E�ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:-�V wa C Q <br /> PATE ISSUED��/� D AREA ! L <br /> APPLICATION ACCEPTED BY - DATE <br /> FINALINSPECTION BY <br /> GROUT INSPECTION BY <br /> �.---.._....._�._..--- <br /> DESTRUCTION INSPECTION BY DATE _.._. <br /> COMMENTS/CONDITIONS: <br /> FAG# -- --------- <br /> VACCOUNTING ONLY: AID# - -.........— PERMI7ISERVICE# INVOICE <br /> RECV'D BY DATE _.....-_.--.- <br /> ES FEE INFO AMT REMITTED CHECK# $R#OO SS8`� <br /> ?.S6 oqe - !i g oP <br /> __ `ENCROACHMENT DOC <br /> -' WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT <br /> C-57 --- Wla.t PCRi APP <br /> YHD JeDI 111510Y(4VE01 <br />