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FILE COPY <br /> SAN JOAQUIN COUNTY <br /> {tom NVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> %t MAY01TAP§one:(209)468-3449 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> \�,�• °>;��N=c, UNIT IV <br /> ENVIRDI W1ENT HEALTH WELL PERMIT APPLICATION <br /> PERKT/SERVICES Wb I D�T <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W,-r <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,Cokintv nevelnoment Title.chanter 9-1115.3 and the Standards of San oaquln County Environmental Health Department. <br /> -+c,. �7+� (,� r �/� Assessor's <br /> Well Locat l b : Cross Street`�Ol�a�6 CiAty� I C Zip 9✓3"IlY Parcel# �•w• <br /> Property^ �p A f�/ /► /1�y,�A rt <br /> Owner G1T� b� 1 F—J�1 Address t�i)lt/lEAST <br /> lL►�c1�>< F � ity I YaC Zip /✓3 Phone# — �� ���0 <br /> Dr 220 IV• E S 1 S I • Cit W�� Zi Lic# �Phones <br /> C-57 Contractor I� 1 Address y P <br /> 50 <br /> Consultant/Sub Cntr t: FVM Address 1101 " X* O t•.12 f City kND Lic# Phone 510—Ul�y3 <br /> �l q C , 34.735 ,Township L-- J Range Section 5 � � 2 <br /> GIS Coordinates:X �2� •43' 1� (N ,Y <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ESTRUCTION(CHOOSE TYPE-F'OW) <br /> SOIL BORING# OVER-BORE DIAMETER_ /D.25" <br /> WELL# ❑ PRESSURE GROUT <br /> *OTHER GROUT SPECIFICATIONS POVI&O <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS/ It <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE !D ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS,Sr ,* TYPE OF CASING:❑STEEL PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED)<AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes/*No (NOTE: <br /> MAXIMUM FREE-FALL DDE/PTH IS 30') <br /> [:1 SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS �VI T 1J-- �"� po • a <br /> Kd <br /> ❑OTHER: �/ ❑OTHER: ,, AAPPROX.BORING DEPTH I 1 BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> lr abQyldpyl rylp }- _ _ COt DUCTOFCASING_P�nPnSED YES,list specifications in comment section) <br /> COMMENTS: l�C-llL.1''w�/'77�1r/ <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 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,an all applicable California Laws. <br /> / Q go•ea C e I NIS-f / Ge"Atw-ix <br /> Signed /I !�(p� /r.L/i(^ Title/Company �j�c 1 __V �7 <br /> Print Name V��N VI �I(�G Date + <br /> QQom,��'\ DEPARTMENT USE ONLY <br /> � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: [�OvV � <br /> WORK PLAN DATED: ( v O <br /> APPLICATION ACCEPTED BY DATE ISSUED D '�CJ AREA <br /> GROUT INSPECTION BY FINAL7IiN q E ION B P+ a TED DATE � 9 <br /> x 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 /> ?SRO 2,- 1 VSD �& / �l-0 .S <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC t�) _ /q <br /> EHD 29-01 11/5/07 WELL PERMIT APP ��!! <br />