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�GJ—'11-08:09: 23AM; ; 916 679 2422 # 2/ 4 <br /> 04 I" SAN JOAQUIN COUNTY <br /> 50. coc <br /> Y1: <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.orG/etid UNIT IV <br /> LrF00. <br /> WELL PERMIT APPLICATION <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 Dev�e�lo ant Ttl_e.c g Aer 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> V�/�j'J LtX f"-ctnCr is tis �P, ✓� q �t Assessor's <br /> Well Location G6I S! CLH Cross Streel (�, a/ City Zip�453ui'Parcel# 11J <br /> Property Jxv 70a n <br /> Owner �N-r'ty�i Address Wd G/ Cily Zip Phone# 'meq X30 <br /> �p � SRn/a-FG <br /> C•57 Contractor l/VD� /e�tCe�ddress t 30� / egpYCItCL fIV2 City�S nrr�s Zip g0610Lic#'G57-�'(01'fljPhone 4 3 00 <br /> Consultant(Sub Cntr -01fiddress2-a7o6�1`r1W Qak9Pr City SALu%:-a"s,fo Lic# Phone 91667929/3 <br /> GIS Coordinates:X 185 Y wa b ownship 'Iw25 Range t� <br /> I\SE Section <br /> WORK TO BE PERFOR <br /> ❑N W W L1BORIN CP.,GEO�Pf3gB�E,�iYD PUNCH,HANG-N UGER,OTHER') El DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# G.!✓FJY IL GI d El 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`V 2/r ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:= <br /> �- <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR < 0 <br /> MUD ROTARY y�DEPTH OF GROUT SEALT�[`too/ TREMIE TYPE TO BE USED 0 AUGERS X�HOSE <br /> ❑AIR SPARGE/OZONE �,I PUSH POINT(GP OR CPT{�/'lt' t GROUT SEAL PUMPED�Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH ISf 30')/ L <br /> ' IL BORING 'l❑HHANDAUGER GROUT SPECIFICATIONS <br /> ,>,-,-"`O i�el1-/cylrf-c-Slr tyvl� : �fJ/h Qr�'r�ft•P'�r 7�GoG�rfriN/F- / <br /> /JacAIOoOp I <br /> ❑OTHER; ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR (I STOVE PIPE <br /> _ R CASING PR POS D RYES,list spe6OcGo�5In mmmetse <br /> COMMENTS: yi Vh—r /0CM�'6 o2 r✓Or' mRGpC <br /> O11ec7etr <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 Iicablle^CaIllpirgjla awss./,t,,�//� , <br /> Signed e{ //II��V(/N�//�Zr://,�"" t Title/Company l/✓/C� LYl L�"` AL1 p Print Name (-iYl�hl rt' 1 L!/L /✓�� Date 47tt <br /> DEPARTMENTUSEONLY 7 * 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 25l'?oU <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: C-F7 t dj <br /> il <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIVSERVICE# INVOICE <br /> SR#00S-5-06L5 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENTOOC <br /> EHD 2401 11/5/07 WELL PERMIT APP <br />