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SAN FILE COPY <br /> o JOAQUIN COUNTY <br /> Q" ENVIRONMENTAL HEALTH DEPARTMENT <br /> IN: SITE <br /> i 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> Telephone: (209)468-3449 Fax:(2G9)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> xoR- <br /> q <br /> V WELL PERMIT APPLICATION �� s <br /> NON-REFUNDABLE PERMIT EXPIRE YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit46-dbnstruc nd/or install the work described. This application is made in compliance with San <br /> Joaquin Countv Dry Plnpment Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. tr2 t 0'F <br /> Hl 1 Asses �I50&*AL HEALD <br /> Well Loca•,.,., $U CK Street l �1��-Y C�-� /41lQ, City Y .Zip 95376 Parcel#'-2315026ERVICES <br /> Property o !, <br /> Owner- Address y 60DIUjIdS 5.Stop 100 City E, ZiP69179 Phone# <br /> C-57 Contractor n2.1)2 Cpv'e- Address �A'M1c-S-su"I A City Lic#50&"? Phone 530- 1- 6tao <br /> Consultant/SubCntrAW-( G-wr„a-hr;x Address 01"64e,.4.. JA�a City Gaa.kiatj Lic#60A1 <br /> hone 5/0-(pW-1//00 <br /> .i f <br /> GIS Coordinates:X -1211.�L/ _,Township Rang( Section <br /> RK TO BE PERFORMED: <br /> NE ELL/BORING(CPT GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑ DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING#'f�Y''3I"(R �2.T .� 'IR�-3TTRy ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER I GROUT SPECIFICATIONS <br /> COMMENTS: /nN�_ it iri.�e caGL� (TRy 31,719 2214!1)11 TRY—aS TRY-36)(i�' _��� �pqs <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING [3 HOLLOW STEM DIA.OF BOREHOLE " ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: (� <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER v <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED El AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(OOR CPT)_ GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS1'��gy4 Cc.hy Qt,+ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ID w ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSE (if YES,list 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, d all applica!: California Laws. <br /> Signed /'� lC�-� Y <br /> an Title/Com <br /> ,�{{� CA <br /> P 4ME �2OYY�0.�rik <br /> Print Name c..y,t ���- � Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESjS: �� Gy • p sT/� 466 <br /> WORK PLAN DATED: f �O�a �p Zell <br /> APPLICATION ACCEPTED BY DATE ISSUED T"Z�'�� AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR#D&L%6 <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT E /,�_cD.(_ <br /> EHD 29-01 11/5/07(WEB) F B L E C Off"wELL PERMIT AP (/ <br />