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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> pr'E. 600 East Main Street, Stockton, CA 95202-30290 `II;; MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.s' - � 1, UNIT IV <br /> WELL PERMIT APPLICATION DEC 0 4 2008 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE isfW i0NPAEE�NRT,/HrECALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This appficatidnT(s`fhAd51iX9smpliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> � M�f R� 1 11 <br /> Ke,t.racF pbo (;6L '6V% q Assessor's Q �, y^'A <br /> Well Location 5135 E h e ross Street City ���� "" Zip q Parcel# 06 1-QI�'�(D/W <br /> PropertyII,� I _ Stj5'65 W 1 f- PY n,, ,( S- dy4 + Zi J al 51-4 <br /> Owner vVST�b E rr ((���Tvrl _.'_".'+'A,,,d,�d�j�re—"s(fs ✓CJ O K` n I' F—- City �.,��L,� p SXG Phone _0v,� <br /> C-57 ContractorAk d -tC�ryIVlYOiwVVNbfL�s4 n31 SWw Ott! CitySlO(*111 Lic# �'i'I Phonel-ft'51l'93D <br /> ConsultanVSub CntAU0.P1CQL6.tA1f&t40" DnS City SWMA Lic# Phonel�T(N SII�N� <br /> GIS Coordinates:X Y ,Township Range Section <br /> ORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER`) -1 DESTRUCTION(CHOOSE TYPE BELOW) <br /> r ® SOIL BORING# I l -Idl FD''LO r pi-2t I rl`Zl &231 nl"l�{ ❑ 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 Z ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL-66I l(A TREMIE TYPE TO BE USED p AUGERS❑HOSE <br /> YVC, OW'S <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 'T HAND ftp/1II pp <br /> lD A <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (K YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> hereby certify that I have prepar this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all appli .able h rnia Laws. <br /> Signed Title/Company YYU�I r/ 'V`^^'••"` aftrmIran In ' "----' <br /> 9 )2-)'�O.OSL <br /> Print Name w el Ute' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: a'��D <br /> /cY1�'/-�. DATE ISSUED o S <br /> AREA 6'�C <br /> APPLICATION ACCEPTED `e <br /> GROUT INSPECTION BYFINAL INSPECTION BY 1 DATEDESTRUCTION INSPECTI+BY <br /> 1� [[++ DATE ./ <br /> COMMENTSICONDITIONS: ��-�- OIM I'c� 1lVO✓'r C7 . r�k a l.tn^' � � <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> -L oto 81.00 4g1.00 zq 1A5 tit R# b1�� <br /> C-57 WC _ �-WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELLPERMITAPP <br /> EHO 29-01 1115/07(WEB) <br />