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0 SAN JOAQUIN,COUNTY • FILE COP Y <br /> OEENVIRONMENTAL,HEAkTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sioov.oro/ehd UNIT IV <br /> 2 5 2008 WELL PERMIT APPLICATION � �1 c O <br /> ENVIRONMENT HEALTHNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SB/" <br /> PERMIT/SERVICES <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 /> I'k43to No-hl P.O�I dot Cil 1 1 Assessor's <br /> Wall Locatio__n,A1 //n,vwFrT^- eeQpL yyCross Street �o y yam,l Zip 1. N'7 Parcel# nS� 1,1 o 1Pro0 <br /> OwnerY�-�CQM.LGM� Ak4.0 {/Addressi,: ki l ��'1()Y-h&nfACity Lor7t.1 Z09524'Z Phone# <br /> P�^CA�o <br /> C-57 ContractorT c}nn ins Address 3t�5 LUy1)r.n ✓ City Cs,�cA,oar-� Lic#8igS43t PhoneCj1 �o ARSS(oL( <br /> Consultant/SubCnIT12it e-Stsevr.✓ Address351 1ZueSS IZA_ City o' Lic# Phonelpe—scr.1 2C i <br /> GIS Coordinates:X 38•W 1 _r ,Y —117i1.X I (r ,Township Range Section <br /> WORK TO BE PERFORMED:�� �.�t -Z041, 92, <br /> NEW WELU13ORING(CPT,GEOPRO J DROPUNCH,HAND-AUGER,OTHER`) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> 1,2-❑SOIL BORING# 12, —C7'1� [1OVER-BOREDIAMETER <br /> [IWELL# ❑PRESSURE GROUT <br /> I 2L*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: A '11A{-p1 OF 12 ll,2[ v)G1S �ov (J1r„tfn/ SC— <br /> MnPI-CJa Ov1 01-' L. 7lni_1\ (w)1 1 <br /> i2 c.(y��d, ; )r'{-ON .n A v1G % v C+C I o r71 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING KHOLLOW STEM r DIA.OF BOREHOLE <br /> lq �C 2� ❑MULTIPLE CASINGS[I MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 1(T�wa& TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL r TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:IKYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> '9SOILBORING [I HAND AUGER GROUT SPECIFICATIONS cR.kMne-ky� S IU✓L/4 <br /> / /� r <br /> ❑OTHER 1p ❑OTHER: APPROX.BORING DEPTH ��`(0 O ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> r r/ CONDUCTOR CASING PROPOSED (if YES,list specifca9ons In wmmeni section) <br /> COMMENTS:_I G,V Q e✓ i.V t'1�1^1 a 1� Go v1 al.0 r4.0 <br /> a-ta✓ 4 r/ <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 1 accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,aannd;all applicable California Laws. 1 <br /> Signed L/L--�` 1/ L— Title/Company O(. G7 1 •T <br /> Print Name 2_ 11 CSV Date I I Z <br /> DEPApRT�MENT USE ONLY n ' <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 3'T"3 (i00(-C <br /> WORK PLAN DATED: / p, <br /> APPLICATION ACCEPTED BY DATE ISSUED 6D ^� a AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PECODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 V WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V <br /> ENCROACHMENT <br /> 'DOC <br /> EHD29-01 1115/07(WEB) APP <br />