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SAN JOAQUIN COUNTY FILE COPY <br /> r, ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 6 ( 0 East Main Street, Stockton , CA 95202-302 a n2 IV <br /> TION <br /> o- * Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: ;;z SU <br /> ov. IV <br /> WELL PERMIT APPLICATION OCT 2 9 2008 O <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE VIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicF6RMhWWWPE__&oe with San <br /> Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> n v11• Assessor's <br /> Well Location oZ rt�r4 ss Street Gran Ol n Aeiywlc I City `J4-oSIC- '1 Zip tl5a04 Parcel jap�, ce ozk <br /> Property <br /> Owner /Y1a ,r IL S?e, Int - Address B53T LO I bLm t4rAeCltY S `112Gkbr ') Zip Phone LI C . I A t, t <br /> C-57 Contractor C'aSaaok2 Address NO'ba OML P er Lp City A ' . .1 . Zip 95g41 Lic # '�tlsl0 PhonecllW� � <br /> /� I Bert <br /> Consultant/Sub Cntr ARCADES Address OISoc�r-rrprve City r=' lSo vh Lic # Phone <br /> S:, ,hL its <br /> GIS Coordinates: X 'da, r11#6_ - Y 1 'DL l ."62gb Township Range Section <br /> NRK TO BE PERFORMED: <br /> EW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) Ll DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ OIL BORING# ❑ OVER-BORE DIAMETER <br /> &WELL # /Vj Tp ❑ PRESSURE GROUT <br /> ❑ *OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYP OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n <br /> MONITORING Ig HOLLOW STEM DIA. OF BOREHOLE _I_S, S L7 MULTIPLE CASINGS E1MULTI-LEVELWELL CASING DIA: Z <br /> ElEXTRACTION ❑ AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑ STEEL 19/PVC ❑ OTHER <br /> -1 <br /> 11 VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEAL �_ 7REMIE TYPE TO BE USED Lh AUGERS NJ HOSE <br /> ❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED:`ZYes ❑, No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS L1 —M) <br /> ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH I)C) " 1 S Lir BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br /> CONDUCTOR CASING PROPOSED VPS (ii YES, list specifirav in mmmen <br /> COMMENTS: � . [o2S=lrir_h a.o}Ly c�� heJl-r ,r ��r cra` �iS- L� �Se • 111r Sia \ er1 1 � L re'a.-e.. ' <br /> it <br /> ps a v d tk a� s+ zv .� P p e� <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 applicat <br /> Regulations, and all applicable California Laws, ion and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br /> Signed e �y�s n Title/Company � �-C...c.,�\ � 1 I)0%,\.l, Yv� <br /> Print Name ThnT :rcN` ? r!. Date 1 �1 Z-S(i off' p <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE4BY <br /> l� ' 3 ,l',SLb <br /> WORK PLAN DATED: Q <br /> APPLICATION ACCEPTED DATE ISSUED L—' �Dg 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 "HM <br /> MAL <br /> `� l0 29 - <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ERMITEHo2e-01 11/67 <br />