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APP — 8 2008 <br /> lENVIROtdlyi j`l i HEALTH <br /> DG <br /> }? San Joaquin County tznnT/t <br /> �r1 --�,r,-r,>ERVICES <br /> r' Environmental Health Department SITE <br /> 600 East Main Street,Stockton,CA 95202-3029 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNIT IV <br /> " Well Permit Application <br /> NON41EFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appicadon Is hereby made to San Joaquin County for a Penmlt to WSlrud and/or Install the work described. Thio application Is made In wmpllan with San <br /> Joaquin County Development Title,Chapter 9.111&3 and $tondards of San Joaquin County Emironmonlal Health Dep n anL <br /> jJ�� // // /C YJ //�1 ,Af //// Abceaaow <br /> WELLLocation R17/e//QLId- R,p�,_i Cmsssunt Vcdrlrt&tVI.AT/ Zip Paroew INS-oO-11 <br /> PROPE / n ��""'' <br /> Owner /1 �7� zd Addresxsj9d 7r.jnz �aui<c.-Qr CIIY���p.�I.7a.[_Pnoned 109�gN/f V'S�o <br /> 047 contractor ( )f7e,_� Address 1461 UES{Ti>nr .4u City P uc+f ZWjkhonee SM a36-6ZSZ <br /> Consultant/SubCnlr 1%ecSir_,.._ . J;]Ut* Addresa,Wl-(! 44U..tl/r.( city, ar7619 1•3' ahor�ca 975`'�/>/i/tAS6 <br /> GIS Coordinates:X Y Township Range Sadton T <br /> WORK To BE PERFORMED: <br /> )NEWWELL/BORING (OPT,GEOPROBE,HYDROPUNCH,HANDAVGER,OTHER-) aDESTRUCTION (choose type below) <br /> B SOIL BORING e 0 OVER-BORE. DIAMETER <br /> `a Ovcl r,T T-. 0PRESSURE GROUT <br /> a Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TY PF CONSTRUCTION SPECIFICATIONS <br /> 'MONITORING g HOLLOW STEM DIA.OF BOREHOLEfoL' U MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA:-ZL'_ <br /> aEXTRACTION flAIRHAMMER/ORIVEN CASING THICKNESSah L40 TYPE OF CASING' 13 MELjk_PVC BOTHER: <br /> B VAPOR B MUD ROTARY DEPTH OF GROUT SEAL L-1 TREMIE TYPE TO BE USED. B AUGERS ,'HOSE <br /> t AIR SPARGE/OZONE 0 PUSH POINT(GP orOPT)GROUT SEAL PUMPED: Was 0 No /rNOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> B SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS of n Cwt a r _"I. S'!K Ik In .n }p_d7ArL=1c_r- <br /> B OTHER: £OTHER.S'nn i f. APPROX.BORING DEPTH '2 M)t 11 B BOLTED TRAFFIC BOX or ',STOVE PIPE <br /> CONDUCTOR CASING PROPOSED,. bja (4 YES,Hat specifications in oomment semen) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, 'i7 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. t! <br /> I hereby certify that 1 have prepared application and that the work will be done In accordance with San Joaquin <br /> County o inancBS,Rules a Reg ati s,and all applicable California State Laws. <br /> [� <br /> Signed) �_Twe/Company �T�1T Arca C"3 <br /> Pdnt Name„ � [ 's.1 N Dela ! C= <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Applkaden Accepted BY —�—Date Issued 4 !a D 0 Ara <br /> Grout Inspection BY 71 OI 9: Final kwpection By�J Date <br /> Destruction Inspection By Oattems —�-- <br /> COMMENTS/CONOnno": <br /> ACOOl1NTING ONLY: AIDF FACk <br /> - - PE CODES FEE INFO AMOUNT REMITTED CHE IT-tt1ERViGE-Ht>41UE — <br /> �0 ( �`I 3,730Lf Y o a� 53B <br /> C-57 WC----WAIVER— C-57 Letter of Atithorization to sign permit,Encroachment doc-__, <br /> EHD,29-02.001 WEB <br /> 9111/2007 <br /> 1:10 39Vd 951 660Zb669Z6 L1:1,T 800Z/T£/£0 <br />