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JUL-21-2008 11:53 E.P G 415395999 P.07i30 <br /> • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> ( J 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)466-3449 Fax:(209)468-3433 Web:www.siaov.orq/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin Countytor a permit to construct and/or install the work described. This app6catlon Is made In compliance with San <br /> Joaq um County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Aarcel#4411 1 sn�� <br /> Wen Luca n s QGmss S at oYA O City ZipgS'1d3 Parcel# -'If✓i F V <br /> Prope �1 � <br /> Owner rens Ir City ZI�YPhone A I <br /> S M r 1 <br /> CS!Contractor ! A dress .City (��rrr•••--- Zip Ic-,(# on <br /> ConsultanUSub Cntr Address � Clly Uc X�®�e <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> W RK TO EPERFORMED: - <br /> NEW LL/BORING(CP ,G' P OBE,N OROPUNCF! HA UGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# YD E]OVER-BORE DIAMETER <br /> ❑WELL# C]PRESSURE GROUT <br /> Z]-OTHER GROUTSPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE)�-3n El MULTIPLE CASINGS[I MULTI-LEVEJWELL CASING DIA: <br /> [3 EXTRACTION El AIR HAIAMEPUDR1VEN CASING THICKNESS ,. vu TYPE OF CASING E]STEEL Ly PVC [I OTHER <br /> ❑VAPOR 0 UO ROTARY DEPTH OFGROUTSEAL TREMIE TYPE TO BE USED❑AUGERS El HOSE <br /> ❑AIRSPARGENZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED es ]No (NOTE:MAXIMUM FREE-FALL DEPTH 15 30') <br /> ❑$OIL EO G Or NAND AUGER GROUT SPECIFICATIONS <br /> �(/OTHER OTHER; APPROK BORING DEPTH ❑aOL DTRAFFIC a0X OR 71STOVEPIPE <br /> CONDUCTOR USING PROPOS pr Yee,4tsp fia0ma n oomrrmnl m=wj <br /> COMMEN S: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby cortity that I have prepared this application and that the work will be done 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulation and allapplicable ifomia Laws. <br /> Signed Title/Companyp►�1Q ' .I -.wa Iter.• <br /> Print Name VI �) Date <br /> DEPARTMENT USE ONLY j <br /> SITE MAP IN UNIT IV FILE.ADDRESS; `S d �I `�• 7 V' w `•MLL�Y„ <br /> i <br /> WORK PLAN DATED: IL&na <br /> APPLICATION ACCEPTED BY /'l - 1 OATE ISSUED -I o2A d Y AREA y\�j <br /> GROUT INSPECTION BY FINAL INSPECTION SY ' ! DATE <br /> DESTRUCTION INSPECTION Uy DATE <br /> COMMENTS/CONDMONS: <br /> ACCOUNTING ONLY: AID# PAC# <br /> PE CODES FEE INFO AMT REMITTao 6.NS " RECV'D BY DATE PERMTT/SERVICE# INVOICE <br /> GS/ WC -WAIVER C6/LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />