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O � M <br /> ' c San Joaquin County "E <br /> rCOVE (� <br /> Environmental Health Departmen V SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 9520I?A ,� 1 2007 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org eUNIT IV <br /> Well Permit Application ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <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 ofSan Joaquin County Environmental Health Department. <br /> ' Assess <br /> WELL Location 3130 W-SWOO Roao Cross Street LA NE City TP.ACY Zip 5+/ rl Parcel#jj-a`1 ,0j0 <br /> PROP �1 1�n r1� f1 � P Q ) E36-�65" <br /> Owner UKI+OAVSrri16LUN Address 4ql IAiNyew, SJR Cit 5 Phone# 0q <br /> l� Y Zi <br /> ' C-67 Contractor M W ILLINCI Address 221)N.I En 5T $r CnyIA I LDZip��ic# 2'33$hone#( <br /> ' <br /> Consultant/Sub CntrSAI(I Address -RAUMlb(AUG 3i� ;ry A�AiNt�# NIA Phone* Io <br /> GIS Coordinatesb : 3 :TTu <br /> 4& �7,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ),'NEW WELL/BORING ggT,TfPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> ' SOIL BORING# (S 't 1 Q OVER-BORE. DIAMETER <br /> LL# Q PRESSURE GROUT <br /> Q-Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECT [CATIONS Q <br /> Q MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:V& <br /> ' Q EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS NIA TYPE.OF CASING: Q STEEL Q PVC Q OTHER: / <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL 0 OANEI TREMIE TYPE TO BE USED: Q AUGERS p HOSE(711') <br /> Q AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXJ�M�7JMpFREE-FAL DEPTH IS 30') <br /> ' )d OIL BORING Q HANDAUGER GROUT SPECIFICATIONS P 1. a/O 0611[ IV IX <br /> Q OTHER:_I]OTHER APPROX.BORING DEPT 6 Q BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSEDPin (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 in accordance with San Joaquin <br /> County Ordinances, ules n Regulations,and all applicable California State Laws. <br /> Signed � Title/CompanyyftrCT EWVIew1'MfoALScic-km t /sia"( - <br /> Print Name Lf�12tn &6VA Date ,ll 10-1 <br /> DEPARTMENT USE ONLY � a� 60 <br /> rf �_/— RC , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /CLL r„ l.J�u+ eclil <br /> WORK PLAN DATED: <br /> ' Application Accepted By Date Issued PL 7 Area <br /> Grout Inspection By —DL—Final Inspection By Date <br /> Destruction Inspection By Date <br /> ' COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_EncFedtment doc Ef <br /> EHD 29-02-001 dze ,b 4ptj-1' <br /> 6/22/04 G <br /> 1 <br />