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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />u U LJrelephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br />\\1 F O _. <br />JUL 01 2008 WELL PERMIT APPLICATION <br />ENVIRQ�,UIENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ApplicaARnNATdr vJd��bQ'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 />Assessor's <br />Well <br />Well Location 1164 " _51LeeLt Cross Street City v�fZ�G/�O11 Zip 9.4'&7 If Parcel # I -?� 1- O 10 -Oe <br />Propert <br />Owner Gaf4.1nS J lL4, b Address ?QLS_C�/ <br />C-57 Contractor U WII, V91-- <br />Address 950110W 1R11Vr j <br />Consultant/Sub Cntr tiidi;less 3/6 ' , a <br />GIS Coordinates: X -12/ 2572 V -?Y 37. �%�10�.4t'7 To nship <br />WORK TO BE PERFORMED: <br />)KNEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />❑ SOIL BORING# <br />f� WELL # AAW-( y /S <br />❑ OTHER �� r>t�> S�ezll� 5 eV - <br />61 <br />COMMENTS: — <br />COMMENTS: <br />TYPE OF WELL <br />9 MONITORING <br />❑ EXTRACTION <br />❑ VAPOR <br />❑ AIR SPARGE/OZONE <br />❑ SOIL BORING <br />❑ OTHER: <br />COMMENTS: <br />97 City F 5 V -Z-11 Zip Phone # NS9- 7Y.3 -?317 <br />City 11154t v -AA Z ZIP, 3 Lic # !y/lS Phone <br />9zs =3 l3 -S frCX7 <br />City l9,ii;k1 idoUg Lic # Phone 91h 9�SZ -� 9�!/JI' <br />Range C section �s� <br />C�u�a �� !mss Gi�.uce�5 <br />,®-DESTRUCTION (CHOOSE TYPE BELOW) <br />AID # <br />❑ OVER -BORE DIAMETER <br />-St-PR[ESSURE GROUT <br />—, <br />GROUT SPECIFICATIONS <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM DIA. OF BOREHOLE ff~tt C3 MULTIPLE CASINGS ElMULTI-LEVELWELL CASING DIA: 2 \ <br />❑ AIR HAMMER/DRIVEN CASING THICKNESS-5GK h'O TYPE OF CASING: El STEEL 9 PVC ❑OTHER <br />❑ MUD ROTARY DEPTH OF GROUT SEAL -116 TREMIE TYPE TO BE USED ❑ AUGERS;KHOSE <br />❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: AYes `/❑/� No (NOTE: -MAXIM M FREE -FALL DEPTH IS 30') <br />❑ HAND AUGER GROUT SPECIFICATIONS <br />❑ OTHER: _ APPROX. BORING DEPTH GC/' jj� BOLTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 1 accordance with San Joaquin County Ordinances, Rules and <br />Regulations, and II ppl' able California Laws. <br />Signed Title/Company 7r/ <br />Print Name 1G+�td S�S Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: l3 :5► -ref' <br />WORK PLAN DATED: Lf 2G I his <br />APPLICATION ACCEPTED BY ���.�`r DATE ISSUED O AREA <br />GROUT INSPECTION BY (A' cis Lt fps O� �C FINAL INSPECTION BY�( ,,�-DATE �LOSs- <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />DATE <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE PE # INVOICE <br />3'501 <br />-14 tscf -Ma <br />O L 71 I <br />Oi� <br />I NO4s SR0 VS 7 0 / <br />C-57 WC -WAIVER3503, <br />�/ <br />EHD 29-01 11/5107 -2c l `cz, <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT / NT DOC <br />WELL PERMIT APP <br />