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Ps y. • SAN JOAQUIN COUNTY FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> EKED 600 East Main Street, Stockton, CA 95202-3029 <br /> C MITIGATION <br /> c Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sbov.org/ehd UNIT IV <br /> =arc <br /> Nov 11 0 2008 WELL PERMIT APPLICATION <br /> ENVIRONMENT HEP REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2. ONS IT-05 <br /> PERMIT/SERVIC <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, <br /> chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessofs <br /> Well Locatio?-lEast Vl..Li1 SIICross Street Korkl,, City Zip 96105" Parcel# 1412402-3 <br /> Property �'V�p� rr' LLG.r }o} E Q, y_ p 5"Zo Phone# 4165-SSle9. <br /> Owner GL' t DdM oavrl Address 2. __ +-M-f 64- Cit 6}oc Zi <br /> C-57 Contractor \-foal -r� Address X60 ttvsf torte City Rio Vitkr_ Lic#-+10n}9 Phone+d3- 3� L430U <br /> etn`k.,g aru, P r2- Ur tTS�U CityC& AL C4.lrl'3S1cSi_Phone 91b 16x3 6133 <br /> Consultant/Sub Cntr Addr�els�sf <br /> GIS Coordinates:X .Y "�' �� Township Range Section <br /> WORK TO BE PERFORMED: <br /> W NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') [I DESTRUCTION(CHOOSE TYPE BELOW) <br /> OC] SOIL BORING# ❑OVER-BORE DIAMETER <br /> ,�( et I ❑PRESSURE GROUT Iy WELL# MM �i GROUT SPECI�FIICAT11 N <br /> []-OTHER 1_ r �,l �/D� "' C— <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS r�tl <br /> MONITORING Off HOLLOW STEM DIA.OF BOREHOLE S ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: Z <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SCS, 4 V TYPE OF CASING:❑STEEL K PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL II I 1 or IOUs TREMIE TYPE TO BE USED❑AUGERS RrHOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:9 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS N-0--k &AMAaof <br /> Ir <br /> OTHER: APPROX.BORING DEPTH S of Zd 'BOLTED TRAFFIC BOX OR []STOVEPIPE <br /> ❑OTHER: CONDUCTOR CASING PROPOSED (RYES,list specrications in comment section) <br /> COMMENTS: KW-S 4,;�1015 '~t <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 propaJed this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and 1Hap�al>r California Laws. <br /> Title/Company $}aka Sr.G+ L't} SFro.4ut tvJ:fw�miMks.I <br /> Signed / <br /> Print Name <br /> IF <br /> 2vt ora _Date IU/3o/v8 <br /> DEPARTMENT <br /> rr� ^ AUSE ONLY 35.2 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 'O I O o q <br /> APPLICATION ACCEPTED BY DAT <br /> BY SUD I I� I ',: AREA -t <br /> GROUT INSPECTION <br /> FINAL INSPECTION BY DATE n1 Y I <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEEINFO AMT REMITTED CHECK# RECV'D BY DATE PERMITISERVICE# INVOICE <br /> 356 M 1 -io R# <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT FILE cRC 0 PIU ERMIT APP c <br /> EHD 29-01 11/5107(WEB) <br />