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�(Cl�l <br /> SAN JOAQUIN COUNTY <br /> OCT 2 7 2008 <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-302%RGN111' HEAl-MITIGATION <br /> Telephone:(209) 468-3449 Fax:(209)468-3433 Web:www.sR0V!OrC --,,;,.F <br /> S <br /> UNIT IV <br /> WELL PERMIT APPLICATION <br /> 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.;j 115.3 and tI]IP Stayqards of San Joaquin County Environmental Health Department. <br /> ocro" kvorl Assessor' <br /> a <br /> '140vel 5 Asses ' <br /> Well Location Cross Street 7Z s, /e'r city Z42 el, zipff.2 y Parcel#iZ,47 A <br /> Property r 0 <br /> Owner ;grqdg 401", - Address /F3 '01�vCity Anti Zip ao< Phone# f8 501- <br /> C-57 Contractor 14 -51 Address City 4&JF <br /> A&rl Lic# Phone !rM4WV*o2 <br /> ConsultanVSub Cnt6&j%jLk1- Address city Lic#—Phone -7 <br /> S,0-029 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> )Z'NEW WELL/BORING(CPT��EOPROBE, YD�f UNCH,HAND-AUGER,OTHER*) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ,ET-SOIL BORING# Ej OVER-BORE DIAMETER <br /> [I WELL# [:1 PRESSURE GROUT <br /> R*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: fj:?e az" 112 <br /> C4 'e "2" (" <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> R MONITORING [I HOLLOW STEM DIA.OF BOREHOLE El MULTIPLE CASINGS El MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION El AIR HAMMER/DRIVEN CASING THICKNESS AIA TYPE OF CASING:E3 STEEL EIPVC 0 OTHER 41.4 <br /> El VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL41 If <br /> :!�TREME TYPE TO BE USED 0 AUGERS 0 HOSE <br /> [I AIR SPARGE/OZONE SH POINT(GP OR CPT)_ GROUT SEAL PUMPED:El Yes to (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> /es"IL BORING El HAND AUGER GROUT SPECIFICATIONS 1�z <br /> ❑OTHER: E]OTHER: APPROX.BORING DEPTH [I BOLTED TRAFFIC BOX OR El STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if 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 /> 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 /> Regulations,and all applicable California Laws <br /> Signed '—"P-0eA' Title/Company 6--&49144r 101 �'1111111"al^*Pv-jor e of 7V <br /> Print Name 5!7?6oii-e, A2'P4"4 -/a ir;F( Date za <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: rk,.4 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED 4� AREA qq7 <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: -�SA s-ii dzAR.d,,C c4',20 <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> S RV 0 STLT <br /> C-57—WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD29-01 11/5/07(WEB) WELL PERMIT APR <br />