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PAYMENT <br />• • RECEIVED <br />SAN JOAQUIN COUNTY ypv 7 2008 <br />ENVIRONMENTAL HEALTH DEPARTMENTSAN JOAQUIN COUNTY SITE <br />600 East Main Street, Stockton, CA 95202-3029 ENVIRONMENTA�aiTIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sj�goM PARTMp�,�IM( TIGAUNIT IV <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, cher 91115.33 and the, � nd3lc�s of San Joaquin County Environmental Health Department. <br />�(/z %/ C/ i x". /) SCC/ �7 C J Assessor's <br />Well Location Cross Street -1 _ S� City /% Zipgf . 1 7 Parcel <br />Property, l�0, —�'C%L�� ! ✓/t3jC 1 <br />Owner JC —i' Address/f/( L%U/I/ City ri�Z�l/cep j�,2��L,h�one-->J06 'g <br />C-57 Contractor �� (` ` Address ���� S/`� C'1 �City I*V c# 7 ! Phone %9 -"/ ylY <br />Consultant/Sub Cntr <br />GIS Coordinates: X <br />Address City <br />Y <br />Township <br />Lic # Phone <br />Range S <br />Section le <br />,MRK TO BE PERFORMED: <br />NEW WELUBORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER') ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING# ❑ OVER -BORE DIAMETER <br />,In WELL # L ❑ PRESSURE GROUT <br />❑ "OTHER GROUT SPECIFICATIONS <br />COMMENTS: %/✓S'/ll�/t." �✓ C1/��!✓ �/f�✓iJ// /G C `�% �X//E'-1�r%/l�✓ �✓C CL- /l�C �7t/E' 1/ <br />/✓Cd�ih`�/�N P/�c pC:R j y Q'1,��r1� _ // -7-/L <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS %K <br />❑ MONITORING HOLLOW STEM <br />DIA. OF BOREHOLE S ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 0 <br />EXTRACTION ❑AIR HAMMER/DRIVEN <br />i <br />CASING THICKNESS © �/ TYPE OF CASING: ❑ STEEL ❑ PVC OTHER ARI-Ks6 f( <br />❑ VAPOR ❑ MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ❑ AUGERS ❑ HOSE <br />❑ AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ <br />GROUT SEAL PUMPED: ❑ YesNo (NOTE: MAXIMUM_ FREE -FALL DEPTH IS 30) _ <br />'4Lf- -7I <br />l- S/sl, ��� ��/� rI'Ve <br />661- <br />❑ SOIL BORING ❑ HAND AUGER <br />GROUT SPECIFICATIONS ` Z�fr <br />❑ OTHER: ❑ OTHER: <br />APPROX. BORING DEPTH -:15,7 Fi ❑ BOLTED TRAFFIC BOX OR ❑ STOVE PIPE d <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: <br />f^ <br />V \ <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 th' application and that the work will be done I accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and all applicable r is Laws. <br />Signed <br />Title/Company <br />L n <br />Print Name /` �/(T%7�3 �C �'�//�� Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />,( <br />APPLICATION ACCEPTED BY �zli t <br />» /�✓'� t' DATE ISS ED (1 7 02 AREA <br />S <br />GROUT INSPECTION BY �� �' 3�'/k <br />�Y" FINAL INSPECTION BY /(/ 1J' 0/667 A- ATE <br />DESTRUCTION INSPECTION BY <br />DATE <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE <br />PERMIT/SERVIC INVOICE <br />'4Lf- -7I <br />yq <br />C-57 WC -WAIVER <br />EHD 29-01 11/5/07 (WEB) <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />WELL PERMIT APP <br />