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• FILE COPY <br /> SAN JOAQUIN COUNTY <br /> < ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street,Stockton, CA 95202-3029 MITIGATION <br /> o Telephone:(209)468-3449 Fax:(209)468-3433 Web:Wwwsioov.orglehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> WAX3' Air _. _ <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to wmbuci and/or install the work described.This application Is made in compliance with San <br /> Joaquin Countyjleveloomern Tltle,chavter•9-1!2I5.3 and the Standards of San Joaquin County Environmental Health DeparimenL Assessors NA <br /> I"'• 4• �O�o^ 95L! <br /> al(LowUd-n�301u w._ _Nassj�treet � _.% s7ZG Zlp _1 <br /> rope <br /> Ay( 1� l /•///+r y',-rr r r<,1.J L✓c� V CftY S4D�'�a.� Zip 152ot Phone# 2o4-9Yd'-`7891 <br /> Owner ivt••- aa�fe T-T '"Address M <br /> G57Cantractor 1),&&4 Addres�5'7dC /coa t City 9 9((Lic# 5/ one 4ZS313^58F�� <br /> L�v ,ASyal. o,.,,tr.y nue s" r3o n (4 7LIc# Phone 7d7-9J3-Z3 <br /> ConsultantlSub Cntr G..zl �Gtei3 ddrelss1yrs� I) . city <br /> GLS <br /> —h'�- <br /> GIS Coordinates:X <br /> 3fs •C�5 Y—IZ-I. 3SZ Township Range Sectlan <br /> WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW)NEW WELLI80RING(CPT.GEOPROBE,HYOROPONCH,FiPN0.AUGER,OTHER-) O OVER-BORE DIAMETER <br /> C3 SOIL BORING* yy-- ,RpRESSUREGROUT <br /> 0 WELLS I GROUT SPECIFICATIONS G� <br /> ❑-OTHER <br /> COMMENTS: �,✓e� 4.. �� / 4 io,,.+w! oi.' o.. t <br /> /AC]OF WELL INSTALLATION.TYPE CONSTRUCTION SPECIFICATIONS - <br /> �{,MONRORING f]HOLLOW STEM DIA OF BOREHOLE � 0 MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA: <br /> /❑EXTRACTION 0 AIR HAMMERIDRIVEN USING THICKNESS A44- TYPE OF CASING:0 SrM PJC ❑ OTHER .t/A <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA1 WA TNEMIETYPETO BE USED❑AUGERS El HOSE <br /> Cl AIR SPARGE/OZONE 0 PUSH POINT(GP OR CPij_GROUT SEAL PUMPED:)VYn 0 No (NOT/E:MAXIMUM FREE-FALL DEPTH IS 30) <br /> L3 SOIL BORING [I HAND AUGER_�_. ,--GROUT SPECIFICATIONS Poo �..i ee^e 11•// v <br /> ❑OTHER: 13 OTHER: APPROK BORING DEPTH AIA D BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDIJCTORCASNGPRCPOS (If TEa,t>t NmmiierA zaim) <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 haw prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rulee and <br /> RR#911 Ngris,an II opplloable Callforn S. <br /> ad -rdwCompanY L�tial A�r e l � re(117 <br /> & <br /> Pdnt Name _S�o h r i Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED,._ yt�9 <br /> APPLICATION ACCEPTED BY - DATEISSUED • 10. 09 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> / <br /> COMMENTSICONDITIONS: <br /> I <br /> ZING ONLY: AID FAC#FEE INFO AMr REMITTED CHECKS RECV•D BY DATE PERMITISERVICES INVOICE <br /> CWC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT /ENNGRUAAC MENT DOC <br /> EHD seat ttRalr C+•Eel 04.6rdA " mu PEkM#APP <br /> �!L• Ll •G sv oZ35 <br /> ru [ P-npy <br />