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:'C <br /> SAN JOA UIN COUNTY y MVEDD <br /> ENVIRONMENTAL HEALTH DEPARTMENaP 3 Q 2008 SITE <br /> <� <br /> 600 East Main Street, Stockton, CA 95202-3029 �qNEALT' ITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WM�,IIgl�►Qldl� UNIT IV <br /> PERNiIT/SERVICES <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 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 11 Assessor's <br /> Well Location 3lb NOY}4MaL.g4CrossStreet 0-- LDCA<,�trwa City L.cCN". Zipc%ICAL> Parcel# C:y►� 3Gll <br /> Property <br /> Owner 'De%ry 41 3-,6m �O-YSSo►'I Address 123 He��Q\beafq ��City I-o�`� Zip CJS242Phone# 2e>9-3--I- 7-345 <br /> C-57 Contractor 9c-A Address 3Gtt IFIIV*.Dycity Lic#0%5 9 lRone 131 -C-b--90t <br /> Consultant/Sub Cntr deo Zes3ioVc4Qdress S$5 L Acry ti S�- City `1 c$P- Lic# b 15 L-PhoneLKZ- 3 5 7 D6`kS' <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPRO�gEE HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# g L55-1 tkcs�►c�L1 Sn�$ swue5t $�7- _1) ❑OVER-BORE DIAMETER <br /> ❑WELL# J'PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE:�z 1" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: )JA <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS A-�A TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER tj 161\ <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL S / TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> 1 <br /> OTHER: �C� OTHER: Geon o�Q_ APPROX.BORING DEPTH S ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (d YES,fist specifications in comment section) <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 S L Title/Company �Vbl� I`� "�!i�Y l} �u�rJ��S jVt��-(�►1 <br /> Print Name Date <br /> // / D��E��""PA""RTMENT USE ONLY <br /> N , <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /1� . 41&Z41 51CA-1.t?i�" Lb� <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY � DATE ISSUED `I o D8 AREA ( p <br /> GROUT INSPECTION BY /\ i'l FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY <br /> C DATE_ / <br /> COMMENTS/CONDITIONS: Z -✓�� pO�i C s �-` - e- �j2n <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> d,9ol 6 g S R#eO SS 7 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PE MIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />