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i FILE COPY <br /> SAN JOAQUIN COUNTY <br /> Wq ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ��/ "" 600 East Main Street, Stockton , CA 95202- 302 �� ATION <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: L� <br /> www.s o . v 1IT IV <br /> `Z ^ � <br /> WELL PERMIT APPLICATION OCT 2 9 2008 FT <br /> r ` 'L 1 ) NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE IffNpp� �� pOp ��NII ITTMeeEN❑❑T�� �H� /IE�� CAC��LTH 6 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This Ap�AChY16A�Y9U19 Sempliance with San <br /> aquin pty Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Ylo ?MY.I W. £ wed !_ c1 �" Assessors O� <br /> I Locatior -'p 7 Cross Street WarSh) rl(?M-7�µ` City 36o V.kor? Zip r1 a Parcel # <br /> Property <br /> Owner Cr�b4l er'/�c3tLY,FA-bn Address 4.25 N , EI DeYnAoSlr. City Gk-ctK4mN Zip 4yzn3 Phone # (Ap% li3'3 - fi' I a. <br /> C-57 Contractor srasAC Address '3ln tTm i \rr \ City 2 . 0 b Cc -d�- Zip {Z Lic # ( 9i4 <br /> '31+510 Phone <br /> litag <br /> ConsultantfSub Cntr A%!Ama Address RSID Q"y)brtee Ste,..\PILSCity VLISUN. Lic # Phone r% IV . `rs' . zu1 =I x 15 <br /> GIS Coordinates: X lf'•- 16} , Y "'�• J�� Township Range Section <br /> ni(K TO BE PERFORMED: <br /> NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER') ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ IL BORING# ❑ OVER-BORE DIAMETER <br /> [•}'WELL # C4a- 1 MW - Myt -12ry� MVJ- 12(, / q'I�Y�I-t�D ❑ PRESSURE GROUT <br /> ❑ `OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TY OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA. DF BOREHOLE 1515 Ly MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ZI <br /> ❑ EXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS 60 = 4r. is LZTypE OF CASING:) l STEEL El PVC El OTHER <br /> ❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED t6 AUGERS ❑ HOSE• Z - psi = <br /> ❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: IJo Yes I] No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) 4 iC - <br /> El SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS cgrAQ. * o _ g� q y �' ^3 'T• lc' � ' <br /> ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH ire;lt0ejevN SO -1 * (yBOLTED TRAFFIC OOX OR ❑ STOVEPIPE •``j <br /> r1 CONDUCTOR CASING PROPOSED a (r YEs. list speHr tions in mmment section) <br /> COMMENTS:-All tta-3r^ � ,Ift. ' rvf -. Fce\ 'Lnyvc�'uL r1rrY' S ria. 1 ' ice D��fvcl• w YvF4 47S -iI"�LI <br /> UL} 1\ by SY[�K 4h �M,IL • PS \t^ph i� t� JY G✓Y Sv .Af , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 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 California Laws. <br /> Signed nn� n Title/Company A- ZCxuS C'IL fAL\-T\Ckt�' i <br /> Print Name c� Date tGI LAJ 4 k <br /> DEPARTMENT USE ONLY - (,Qp <br /> SITE MAP IN UNIT IV FILE, ADDRESS: _ 0 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED _R - ( -0 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br /> $ In R# 6560 5 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCR ACHMENT DOC <br /> EHD 29-0, ,,/ TFILE C fI L I <br />