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WELLOPERMIT APPLICATION ARM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <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 Standards of San Joaquin County Environmental Health Department. <br />Joe POmbOAssessors <br />WELL Location 2360 West &cu A+ LittE Rross Street ?aC-V-WACity 'rf'ACy Zip Parcel# 211R-19-001 <br />PROPERTY Owner 1- EIf VCA, ]rc. Address P. 0. (30),L 11 I City. 0 A I�A�i 'rXZip 152-2-1 Phone# <br />C-57 Contractor G m i D r- &' 11111 I\� Address 930 V+O ` o- �ci City hUr+i AO Zip 14S,1dLic# 4 i SI6SPhone# 02-T 3 t3"Sg00 <br />3011 K; l yore qd� S+e 1o0RaKC ho <br />Consultant/ Sub Cntr S CCJR Znit�nA+funa►IAddress City Gorde�w Lic# 6S �l4 q Phone# l9[6) 861'Oyoa <br />9S <br />GIS Coordinates: X 'Y Township 2S Range s� Section I 1 <br />SJ <br />WORK TO BE PERFORMED: <br />[],NEW WELL/ BORING (CPT. GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER") p DESTRUCTION (choose type below) <br />a OIL BORING # _ [] OVER -BORE. DIAMETER <br />[],WELL # t�,,i - ]f LX -1 � � [] PRESSURE GROUT c <br />[]'Other GROUT SPECIFICATIONS C <br />COMMENTS: 5.a e_ at-i-AC.l\.d. wo4-V pla dor �Ii Lov�j fyuc 1 -ion C(�C i �icCA 1-�'c�,n,s <br />C%� 1 <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �( �1 <br />C].MONITORING (],HOLLOW STEM DIA. OF BOREHOLEg `-100 MULTIPLE CASINGS [] MULTI-LEVEL WELL CASING DIA: Z b' '-I + <br />fi EXTRACTION [] AIR HAMMER/DRIVEN CASING THICKNESS SGh Li O TYPE OF CASING: [] STEEL ]],PVC [] OTHER: <br />[] VAPOR [] MUD ROTARY DEPTH OF GROUT SEAL %rl\ 2S TREMIE TYPE TO BE USED: [] AUGERS [] HOSE <br />[] AIR SPARGE/ OZONE PUSH POINT (GP or CPT) GROUT SEAL PUMPED: 0 Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING [] HAND AUGER GROUT SPECIFICATIONS <br />[] OTHER: [] OTHER APPROX. BORING DEPTH Orr ABOLTED TRAFFIC BOX or [] STOVE PIPE <br />CONDUCTOR CASING PROPOSED V O (if YES, list specifications in comment section) <br />COMMENTS: e <br />NOTE: OFFSITE BORINGSIkEQUIRE 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 in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed x Title/Company P ro j e2-+ (yGOIOn I/S f^ - S CCOP tA"t -nG'I +;d U <br />Print Name r'►G►N\ (/ rad'e\1 Date/ <br />I/ OLI <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2 S (C f?cyacf-- t 7iw.,=2_. <br />WORK PLAN DATED: [V\g,,,c,(n 1 `l 400 <br />Application Accepted By h Date Issued S'(0( /c, y Area z <br />Grout Inspection By Date %a i(C7`- Final Inspection By 0" Date % <br />Destruction Inspection By Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PERMIT / SERVICE REQUEST # <br />INVOICE <br />3SO( <br />S`l•oc) <br />S1566y`6 <br />GIS <br />�;/V o <br />SR# _ �` D6 <br />C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />\� � 0) 00 <br />