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SAN JOAQUIN COUNTY <br /> �. ENRONMENTAL HEALTH DEPARTMENT SITE <br /> a <br /> 600 East Main Street, Stockton, CA 95202-3029 -�� <br /> Telephone: (209)468-3449 Fax:(209) 468-3433 Web:www.secov.or / CI�1`1��ON <br /> WELL PERMIT APPLICATION DEQ; Y 9 2008 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ef`d1Ji�'•.�i�'i.E;'3 i IlEAL.T H <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This applicationI�an1�grrt1U$pffiN <br /> ith San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> Well Location Z_7ZX6* 4ryCW*Y?krossStreet R)IAe. Ay.,,I. A. City Zipr-04 Parcel# i21 -7_10-0fo <br /> Property <br /> Owner 7 Address 1?.O. t3 o x 'l%1 City )Xo s 'rX Zip-15 ZZ1 Phone# <br /> C-57 Contractor 6FIrcan 1)611%vl!e:, Address q50 &we_RZ n City fl�arV,ynezCA Lic#J15�honeZs)311-5800 <br /> Consultant/SubCntr Address 30171c,1dpy-e, R�.So-NOtoCity QQYICACC6Cca4 1P# Phone Lr116')Sfo\- oyoo <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [:1 SOIL BORING# ❑OVER-BORE DIAMETER <br /> ®WELL# _r-Zr Z -3_T--1i -117-15- ❑ PRESSURE GROUT <br /> [_1*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: Oxyd��.,T.�tw. (w1c��•, ,D�J�IQir� ;-6, 3 S- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING WHOLLOW STEM DIA.OF BOREHOLE 81,n ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z n <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS Se k 40 TYPE OF CASING:❑STEEL IWVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL _i 1 TREMIE TYPE TO BE USED[+]AUGERS❑HOSE <br /> ErAIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:h"as XNu (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS p ,�,�( <br /> El OTHER: El OTHER: APPROX.BORING DEPTH 3S ta�� 294OLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I h 1yepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulation nd all a Ii b e California Laws. <br /> Signed <br /> Title/Company 5CA .V"�r , <br /> Print Name Date 121 1 r.l o$ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:q -7 a <br /> WORK PLAN DATED: / / <br /> APPLICATION ACCEPTED BY ¢l+zT 7 mO AREAl;VT <br /> GROUT INSPECTION BY FINAL INSPECTION ` DAT , Q <br /> DESTRUCTION INSPECTION BY DATE r <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 7? $ -3c)' '7 "O ►/4- SR# 6704 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN ,ERM�T �ENgP,,0,1PHMENT DOC <br /> EHD 29-01 11/5/07(WEB) •. WELL PERMIT APP <br />