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oaq '•... SAN JOAQUIN COUNTY <br /> 2-1 ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Kne:(209)468-3449 Fax: (209)468-3433 Web:www.siqov.org/ehd UNIT IV <br /> r \tL'=oR <br /> SEP 0 5 2008 WELL PERMIT APPLICATION <br /> ENVIRONMENT <br /> ``/H/((E�`A�IQQh OW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IP <br /> Application is hepret rN'ad6YkS'a 19y in County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> o quin Coounty Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 77 �nfn A�AA..e��/J 4 T c R 'I Assessor's IV <br /> Well Location WWW M} W t� Cross.Street AW HO 1- 5 City S��I�N Zip 52 Parcel#99,^,y I,V I p q <br /> Property /� L' r i� ,,/� _/ #�'�1"1 al.!—Q 3 1 <br /> Owner CIt7 oFpSAbCV—'/Ir04 Address 34SN. LL rQrg�O//��1.o f8� Cityg��1At1r/1 Zip `ff 2 XPhone <br /> C-57 Contractor 1\49�//1y�sVr— <br /> Address �//��r/,.,O��n� city�� 0 /��/ �� Lic# Phone �Lz p <br /> Consultant/Sub Cntr 5!!lr OC Address 30 (I K(60 -CIr1,���ityPAtj ]t Lic# Phone 6 O '07 � �I <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> RK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOP9Q@E,HYDRPUNC HAND- UGER THER-) ElDESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# 1'(LS —ZI �OhQ d(jh.Q� ❑OVER-BORE DIAMETER <br /> ❑WELL# ./ ❑.PRESSURE GROUT <br /> El'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE OT-4 e El MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN - CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE1020NE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:[3Yes gNo (NOTE:MAXIMUM FR E-FALL DEPTH IS 30') <br /> ❑SOIL BORING f71HAND AUGER X4 GROUT SPECIFICATIONS Y <br /> ❑OTHER: /❑`OTHER: APPROX.BORING DEPTH UO to 04 ❑BOLTED TRAFFICBOX OR [ISTOVE PIPE <br /> GONDUC OR CASING PROPOSED lit YES,list ecRre Ions co mant section) <br /> COMMENTS: 4y — - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCES AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> 1 hereby ce that I have prepared this application and that the work will be done Itiaccordance with San Joaquin County Ordinances,Rules and <br /> Regulatio ,a dull applicable 1'fornia Laws. nn �rQ.�'[�S1 S t!!0�nnl &_ " (0 9 rs t <br /> Signed Title/Company Til S( '�-L �L "9 <br /> Print Name (A . QrL' Date q �/ 6T <br /> MSJ <br /> DEPARTMENT r ' 4PARRTTMENT USE]ONLY� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: "��a W rcA <br /> WORK PLAN PLAN DATED: <br /> �vy1 �Y <br /> APPLICATION ACCEPTED BY' / '` ' �_DATE ISSUED AREA <br /> GROUT INSPECTION BY / FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY Yl i II 1 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# C 1 O I 7 r 1 <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY - DATE PERMIT/SERVICE# I IN ICE <br /> 350 -31 -9 0/d0 SR#5 3(0 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD2&e1 11/5ro7(WEB) _ WELL PERMIT APP <br />