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0 SAN ' '16IN COUNTY 0 FILE COP Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> SV�I� 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> (C one:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.org/ehd UNIT IV <br /> F <br /> AUG 2, 0 2008 WELL PERMIT APPLICATION <br /> ^^Q (J ON <br /> TION-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GLV 6T5, <br /> E�vlrSor<!r�n�l<;r IiF�� <br /> Application Is =ZrpbIRW{�uin County for a permit to construct and/or install the work described. This application is made in compliance VAth San <br /> Joaquin Count)/ p ant Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location Mail WCho-rFJ W>Y Cross Street Frn no AJe.Nt City ftockion, CA Zip 9520(. Parcel# 163'020-1� <br /> Property <br /> Owner L11mm 5ge-js Ii I'tic. Address T'0507 Free,vayl S-1,e Ijre City D.II e3, Tx Zip TTLNy Phone# (q)2) L8T•7fof <br /> C-57Contractor 170% Vv' 1:n�_ Address 399 Sker:'s 176te CityWltf for-%(A Lic# 6939&1- Phone (Zo9)7fii-krlo <br /> Consultant/Sub Cntr AM•EL 4e.-e.M:r., Address 1191 E.All.vi .1 Av<wgf aslel City Fres", CA Lic# 1.0i4r0 Phone Cfr9 14 25' <br /> z <br /> GIS Coordinates:X ,Y ,Township Range Section 841-ZR <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) - El DESTRUCTION(CHOOSE TYPE BELOW) <br /> ®-SOIL BORING# T- d:ru+-(�c41% ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELLCASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 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:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 09 SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH S.3-fca} [I BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Ilst spec icatlons In mmment section <br /> COMMENTS: Seil or:n ;nfl I ed T i w t 'I"ec+ • — e! _rr w I e b eck�•.9er�w�'� <br /> ban�en:{e, fee whacked 4' •+�rG 4 b, lec.+:o,. , , <br /> NOTE: OFFSITE BORING REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby�arlave prep r d this appplicatlon and that the work will be doneIaRegulatippaI 'femlSLawsSigned Title/CompanyPrintName ' Viatten 96 Date 2// <br /> DEPARTMENT USE ONLY Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (?D ��G(L�✓u'l, Wl�y <br /> WORK PLAN DATED: p� <br /> APPLICATION ACCEPTED BY DATE ISSUE ' O AREA o f <br /> GROUT INSPECTION BY FINAL INSPECTION BY a DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> b <br /> E CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DA PERMIT/SERVICE# I INVOICE <br /> o 3 so ad' I SR#K545 <br /> C-57 V WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGNPPERAIIT ENCROACHMENT DOC <br /> EHD 2"I 1115/07(WEB) WELL PERMIT APP <br />