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PAYMENT <br /> • RECEIVED <br /> A" SAN JOAQUIN COUNTY <br /> 7 2008 <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-302%AN JOAQUIN CoutJTY <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:WWW.s' o . ENTAL MITIGATION <br /> c� 4l P ARTMENT UNIT IV <br /> / > . <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 Standard$of San Joaquin County Environmental Health Department. <br /> x/2711-�/h� VO e-: C,4" Pk�;'eRiy -7 Assessor' <br /> Well Location Cross Street City � �� Zip 9s� 7 /Parcel <br /> Property,.,,,, <br /> Owner e� Address Ar/0 C iCty Zip Phone# '9 <br /> C-57 Contractor 4�4 > /; 94tldress IdO �f. �91D/�C City ,ff>v��(1Z/f Lic#7-) ��P/ne <br /> Consultant/Sub Cntr Address City Lic# Phone <br /> GIS Coordinates:X Y Township 2 -�C�" `� Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# f V- ❑PRESSURE GROUT <br /> ❑'OTHER GROUT SPECIFICATIONS Q�\ <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: <br /> YEXTRACTION El AIR <br /> AIR HAMMER/DRIVEN CASING THICKNESS 0"T TYPE OF CASING:❑STEEL ❑PVC/9OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL d IC TREMIE TYPE TO BE USED❑AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes^o (NOTE:MAXIMUM FREE-FALL DEPTH <br /> IS 30'),_ _ <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH F' ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PR OSE (if YES,�'s ecifications i ment section) <br /> COMMENTS: �I✓S��LC�}-i/!Ja✓ CJS-��/N(.�/ L/-tS� � - - <br /> pevPEit 1 y . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 1 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS O <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 nia Laws. <br /> Signed f/J � Title/Company -.5-0f2-10 <br /> Print Name 1/✓ ����7h -� l✓ �� Date c--, off <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 1 �/� <br /> APPLICATION ACCEPTED BY A� A&e �!'�("'�J�t_ Y6�� DATE ISSUED /117140 If AREA <br /> GROUT INSPECTION BY _ �[� ��� � �'�`� FINAL INSPECTION BY DATE 1 i� <br /> DESTRUCTION INSPECTION BY / DATE <br /> COMMENTS/CONDITIONS: Z`LCG� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV D BY DATE PERMIT/SER INV <br /> SR# 4965- 3-9 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />