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SAN JOAQUIN COUNTY 0 <br /> ��� ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> t e ephone:(209)468-3449 Fax:(209)468-3433 Web:www.sagov.org/ehd UNIT IV <br /> JUN 16 2008 WELL PERMIT APPLICATION <br /> ENVIRONMENT HEAL-NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> R ,TaaSE vitE5 <br /> Application is e o 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 Joaquin County Environmental Health Department. <br /> Well Location l_&Z Arte Cross Street ������/�� �r(AI��, �'/� t� Z- Assessor's r� i. <br /> Property T / �--- Y-�- — city �1.�'�o2r2 Zip 1J Parcel# Q?(.S3-�T�'17 <br /> Owner �L.1 Lr-1,,. Address 2- tT City `°lrme I Zip I3t Z2Phone#1j�L'd <br /> TW <br /> C-57 Contractor�YeGrjSIN'1 �Q ILCC Address ( "( ESSe,J city 71r _ Zip-?-gf4Li�c# G 6.� F' Phone <br /> Consultant/Sub Cntr .2_ f #jLfs4ddress_ 6 jFL� _ city IiTr�I'l'e Lic# '^ phon',9f�,��Q�_ <br /> GIS Coordinates:X lww,22 ' (��,Y �) o�wnnshipr^__�1�L Range_ �7� Section <br /> N{DRK TO BE PERFORMED: Foy 3 o� T ��/� ' -�L�d �j' r 6 (/ W �(/'/� D ] <br /> �.]NEW WELL/BO JNG(CPT,GEOPROBE,HYDROPUNCH,H AUGER,OTHER- ❑ ESTRUCTION(CHOOSE/rYPE BELOW) �-3J <br /> '\ SOIL BORING# 2q ko •� ort f5�/mMr'�- OVER-BORE DIAMETER------ <br /> WELL <br /> DIAMETER__ <br /> ❑WELL# __ ❑PRESSURE GROUT <br /> ❑-OTHER _ / GROUT SPECIFICATIONS _ <br /> COMMENTS: A(Qr YL ,I? _ <br /> 61 OV <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ` .HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> bN <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY--- DEPTH OF GROUT SEA4 �� TREMIE TYPE TO BE USED-0 AUGERS❑HOSE <br /> 01,❑AIR SPARGE/OZONE —R4" t P1' GROUT SEAL PUMPED::0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> KSOILBORING (HAND AUGER___ GROUT SPECIFICATIONS te.. �11k,/LLt_ewSs <br /> ❑OTHER: _ i-�O'ft1-R^ APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED _ (if YES,IIsi spea melons in comment rection) <br /> COMMENTS: O_ <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 I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable Cali r i Laws. �,,I <br /> Signed (( �� __1 _Tile/Company !F- PWkZ-t7 r.�k h`� �_� <br /> 1117 <br /> PrinlName —�t1t .L L(4 a N _Date_ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: LIZ` f'V^V'e�v� — <br /> WORK PLAN DATED: 12!j_�W 0.L45&,te, t-wT mi s tk .% F L 69(o?) <br /> APPLICATION ACCEPTED BY _ DATEISSUE � �_AREA—t'L � <br /> GROUT INSPECTION BY _L ___ FINAL INSPECTION BY/�^ DATE �'X <br /> DESTRUCTION INSPECTION��BY�"SGG—��'-- 1 DATE <br /> COMMENTS/CONDITIONS: (Duk* nsA== 3OrnT <br /> Is <br /> _. •��L�. L�y1ke��'�- O� ' <br /> ACCOUNTING ONLY: AID## FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT SERVICE# INVOICE <br /> -Lo 8 tai o SR# CA5 qlir- <br /> C-57 __WC _-WAIVER _ _C57 LETTER OF AUTHORIZATION TO SIGN PERMIT __ENCROACHMENT DOC <br /> EHD 29-01 111W7 WELL PERMIT APP <br />