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JUL-21-2008 11:52 E.R.R.G 415395999 P.05i30 <br /> q � SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Far- (209)466-3433 Web:Mruvu. Dv.pr lend UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT D(PIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor install the work daseribad. This application is made in compliance vAlh San <br /> Joaquin County DWI <br /> lop en Tide,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department 13 ?J OD3 Y <br /> Well Locatioss Sha [ -rl !l Cily Zip Parcel# <br /> Props 1Ownerdress ✓ City n zC-5T Contradress' ly ZiConsultanUdress) IL City <br /> G1--SLLCoordtnatas!X Township Range SenGn <br /> �K TO 8E PERFORMED: <br /> NEW LLfBORING(GPT GE P O� H\ ROPUNCH, AN GER,OrHER'? ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# d ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> -OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> A <br /> Q MONrrORING ❑HOLLOW STEM DIA,OF S0XEMCU51 '3rr [I MULTIPLE CASINGS EI MULTI-LEVEL LL CASING UTA:v- <br /> []EXTRACTION Q AIR HAMMERORIVEN CASING THICKNESS)[__TYPE OF CASING❑STEEL PVC ❑ OTHER <br /> El VAPOR 13D ROTARY OEPTH OF GROUT SFAL REMIE TYPE TO BE USED ElAUGmRS❑HOSE <br /> El AIR SPARGE/OZONE PUSH POrNT(GP OR CP1T,_GROUT SEAL PUMPEIYYee ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301 <br /> El/F OILBQRjNG� e�}�,]r1��1 OHANO AUGER GROUT SPECIFICATIONS <br /> 3 H PTHER• �OTHER APPROX BORING OEPTH O SOLD TRAFFIC BOX OR ❑STOVE PIPE <br /> 1 rAN7L\'10R <br /> CASING PROFOSED (I TE6,ist 6peallo3ncre in mmmenl Eao1�1 <br /> COMMEN 5: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that I havo prepared this applkoatlon and thatthe work wnl bur done I accordance with San Joaquin County Ordlnancas,RUI@s and <br /> Ragulatlona,a d 31I apgllcable Califomta Laws- <br /> sign TiuefCartlpanyQ�►�� f <br /> Pdnt Name <br /> �j DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: S V -` �' 4 Q R- <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED �14d O _AREAyt <br /> GROUT INSPECTION BY FINAL INSPECTION 9Y DATE 3 d <br /> DESTRUCTION INSPECTION 9Y DATE _ .._.— <br /> COMMENTS/CONDITIONS:' <br /> ACCOUNTING ONLY: AID x FAC# <br /> PE CODES I FEE INFO AMT REMITTED RECV-D BY DATE PERMIT/SERVICE# INVOICE <br /> a b B SR#5Lf?2 1 <br /> G57 WC -WAIVER G57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />