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SAN JOAQUIN COUNTY <br /> ER"RONMENTAL HEALTH DEPARTMENT SITE <br /> �F LTJ 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.siclov.org/ehd UNIT IV <br /> • PES � � 2008 <br /> FNVfROW, cN't i-ILALTH <br /> WELL PERMIT APPLICATION <br /> PER,%1i1/sERVICEJ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 2 Assessor's <br /> Well Location VeAk0-t Si i Cross Street F I City t5ta-tuTfl zip �t53�� Parcel#_L56OI0Z3 <br /> Property L/N.•n Pr_i;"fc..;l ro"d C /��1�i{G/D e, 1­1 /fie^+ $'�d <br /> Owner ddres>s City 1 Zip '1 3310 Phone# <br /> � u.w�,h.4,� �. eK 53�uc��s. <br /> C-57 Contractor i�Si 06LtLi tl�[,, Address 2?iy lU• FiaST 1ST City Lf OQ7LA,r�7 Ziptp Lic# uL334 Phone�f <br /> Consultant/Sub Cntr[}_{�'XeNy1R-OTPC(4jiG AddressJIZ4i4 CVKII-P5 WA`/ City 6&oLic# `1x71$1 Phone/fo-SS5l-01-4 l <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> $,NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') El DESTRUCTION(CHOOSE TYPE BELOW) <br /> F-1SOILBORING# ❑OVER-BORE DIAMETER <br /> 5KWELL# NLW—15 ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE u <br /> �, �+r ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNES8�H 4� TYPE OF CASING:❑STEEL I(PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL-TREMIE TYPE TO BE USED,$AUGERS❑HOSE <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 UMQ-NT <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTHn`, t <br /> �y ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED tJ G (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 have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulationsrt'j", <br /> all app-cable California Laws. <br /> i <br /> Signed " Title/Companye -'JV(� t i(�C t N <br /> Print Name O."Islry (�L i� Date •D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED 6 Z 8 O Sf AREA /Y5'3 <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 /> aso5 1'294 le383-'G 36i79 F 362s9 C1V�"i� >; zz tSzyZ SR# aO51376 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29.01 11/5/07 <br /> WELL PERMIT APP <br />