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rL on <br /> �o U San Joaquin County Py <br /> y `{ Environmental Health Depart_,'L�����D SITE <br /> 600 East Main Street, Stockton, CA 9520 MITIGATION <br /> P ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov121rA'/oW, 2008 UNIT IV <br /> Well Permit Application , I <br /> EN JRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATQft"PT/SERVICES <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 of San JoaquiPP County Environmental Health Department. ^1 t <br /> ��r n� <br /> WICK LUND G Assesso <br /> �v WELL ocatior. ..W W �I/ Cross Street Y _City)"VVNI►al� l�Ul ip �5 d Parcel#_ <br /> I�v l�hl - 20 q,- luD_►l <br /> PROP Ye,tr EMF <br /> &R <br /> �`,��/�/� �yy� <br /> Owner ily t nt�ttJI &ROM(t ylq�d ress*0 00 /W W 100 City ��� t'Je ip�7� Phone# <br /> C-57 Contractor �� D Ii,LINt� Address d N I G1�`7'rl,�.,�5-r rr J Cit Q,Mk Zip Lic# 233 Phone Y �2��1`1�d' <br /> Consultant/Sub Cntr MIC Addresses yVf[I+ FolE7jgityVle�r isf l Phone/q/b 'q7 e ✓/cf5- <br /> GIS Coordinates:X - 17 I. L� Y /7, �I 6 Townships Range f/145f Section <br /> WORK TO BE PERFORMED: <br /> p NEW WALL/BORING (CPT EOPRO �.)HY RCPUCH HAND- GE T ER•) ' ESTRUCTION (choose type below) <br /> SOIL BORING# - 'r,�7w iya�- ;'y�-� �� [] VER-BORE. DIAMETER <br /> aWELL# PRESSURE GROUT <br /> 'Other Vv�,`9l(1(t�j � �7�I/VI GROUT SPECIFICATIONS_ <br /> COMMENTS: Il' beodliiff, 10 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING []HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: a STEEL 0 PVC: a OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL'_,FDz?16 t TREMIE TYPE TO BE USED: a AUGERS 9 HOSE <br /> []AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes( o (NOTE: "MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS N vEv460 <br /> `�OTHrE JJL1D �]OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or a STOVE PIPE <br /> t"�i IiL �Q.,,I CONI CTOR CASING PROPOSED (if YES,Ii6t sp cifica�t�iorns in comment section) <br /> COMMENT:i: K/�►�N Y (,( C PKC L <br /> 86 eeeP PC a,L CA51 A46, 59E <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 repared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinpr%es, Rules an Reg [ons,and all applicable California State Laws. <br /> Signed x_ Title/Company NUJE&Tt�IJtIZON <br /> Print Name_ 4 LVAi Daterr <br /> DEPARTMENT USE ONLY <br /> SITE MAF' IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: d7 47 Ar <br /> Application Accepted By Date Issued Area �p <br /> Grout Inspection By Date 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 /> �f. VISA Amur 2 $ SR# — <br /> C-57_ WC=WAIVER_ C-57 Letter of uthorization to sign permit_EnccaeccWeent doc_ 'l• <br /> EHD 29-02-00] WEB 4,e-"4!0 OR Top*- `� <br /> 9/11/2007 oyi�V3 <br />