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IONIEDD <br /> .SAN JOAQIJIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.siaov.org/ehd UNIT IV <br /> WELL PERMIT APPLICATION <br /> tAAY 0 7 2008 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ap t' Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Jo% t l`itI ,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 4 i� �, Assessor's — <br /> Well Location 8ikt)N �1� Cross Street WET LIME wvD City Yt'AC`t Zip 95304 Parcel# s7 76-13 <br /> Property <br /> Owner Pq ALVI ffl k K4U9 S iNCj I-I Address WEKT& iZ ON 00A0 city —1 &'f Zip �S ��Phone# 'Z t%`1- �Z✓rJ-I OZ-�j <br /> C-57 Contractor 12S! Address w N Er15rST- city 4}IG Lic# 33�Zip � Phone by 4 <br /> Consultant/SubCntr Address cfC(.)WATTAVFISI)krE; 1OCitySfgCt34I"t6f*1/M Lic# �1Phone 9lb,97cf.33-7rjS <br /> GIS Coordinates:X 'Y Township 102 Range 7 Section <br /> W RK TO BE PERFORMED: <br /> NE WELL/BORING(CPT, EOP, F-70 <br /> vnROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION(CHOOSE TYPE BELOW) <br /> OIL BORING# VER-BORE DIAMETER <br /> WELL# RESSURE GROUT <br /> ❑*OTHER / GROUT SPECIFICATIONS <br /> COMMENTS: OEOPeo6F,- &RING-i Tp ✓r 35 1 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 'I <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 32C- ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: N 1k <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS N TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL �"' t TREMIE TYPE TO BE USED❑AUGERSXHOSE <br /> ❑AIR SPARGE/OZONE /.1i�PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> >KSOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS �i CEt t J i <br /> �J OTHER:W1 1FY►PU, F'� ❑OTHER: APPROX.BORING DEPTH 052 ❑BOLTED TRAFFIC BOX OR <br /> ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 1, <br /> _ �UJ�EUP k01N6, W11. NAV1 Tr--mPoPA� we u, nA 15 U►JSI`IZIICT�tj OFAPP�PA' I2 <br /> IU-1E k Zel5r--N Arm PVC. 0,461 NC1 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certify that 1 have prepajq this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,a all applicable ornia Law "�Signed Title/CompanyF Rwer—TIFA Il. <br /> Print Name 4 121-Y 51LVA Date .5/lam <br /> q DEPARTMENT USE ONLY Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ���!/�(��. CS��� �✓(lLC-y �I, (P� <br /> WORK PLAN DATED: Q d Q( <br /> � <br /> APPLICATION ACCEPTED BY AREA / <br /> GROUT INSPECTION BY FINAL INSPECTION Ty y� DATE /U� <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK#VL5A RECV-D BY DATE PERMIT/SERVICE# INVOICE <br /> zQo sB 89. D z3�3 C,tc 5. VC) sR# O5i{l-75 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT E, T DOC <br /> EHD 29-01 11/5/07 <br /> WELL R@RMITAPP <br />