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MAl A-2008 16:14 FROM:MWH GLOBAL 916 418 8522 TO:2094683433 <br />u 1 4.1t 4vv i man i a ; ay riot cv Y90j> ovk- r'n" <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax: (209) 468-3433 Web: wvrw-sjgov.org/ehd <br />Well Permit Application <br />P. 2/2 <br />WJUU41 UUL <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Appilcation Is hereby mode to Sari Joaquin County for a permit to construct ondlor instal 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 Envlronmental Health Department. <br />s;" C- Ar � rr - ety- . Assessors <br />WELL Locatlo Cross Street W%�1��s�0/►7 Clly. Sratl�Grtp� Zip 9S�.�tS�pa►eeta N,a C_0. !�LG <br />or <br />PROPE@TY (Z�) <br />Owner S/W 2o%OtwCI�AJ��f Address (Ito 0AZ.c.J-ha,J AVbr City 5�►� IcaFow zip 4 nortes 4sos -3+000 <br />C-57 Contractor 9SS Arr, 1[j&L a Address ZZOA-1• grAST Sr. City1.�7 &A± A Ziplrn!l LIC#j2Z MPhone sPbf.9-2'+Z4 <br />Consultant / Sub CntrMLJI'I/4M#rtuts.Tw�LAdd ress33Zr ,1,j-jRJ, CltyLLC. Lica AJ -4 Phone#9/ -VE0SS4- <br />3 -gal 16.70 <br />GIS Coordfnates" X Y Townshlp Runge Section <br />YYORK T ERF <br />?OEW WE`LL BORING P GEOPROB HYDROPUNCH, HAND -AUGER, OTHER") DESTRUCTION (choose type below) <br />,WSOIt. G , q2 --;L -a--rL), - `t'S 8 n OVER -BORE. DIAMETER 5 <br />Q WELLY/ .XPRESSURE GROUT � <br />p 'Other GROUT SPECIFICATIONS <br />COMMENTS, <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />i] MONITORING D HOLLOW STEM DIA- OF BOREHOLE 3� 8 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: N,�4_ r <br />p EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS N A TYPE OF CASING: a STEEL p PVC p OTHER: <br />a -VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 1,cftl. ktd6. TREMIE TYPE TO BE USED,-WUGERS a HOSE <br />p AIR SPARGE/ OZONE PUSH POINT Ggior CPT)OROUT SEAL PUMPED: 0 Yes �tNo (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />SOIL BORING p HANDAUGER GROUT SPECIFICATIONSPo✓tryA _ liK Net_ <br />a OTHER: I] OTHER APPROX BORING DEPTH 8f- a BOLTED TRAFFIC BOX or a STOVE PIPE <br />CONDUCTOR CASING PROPOSED N (if YES, list specifications in comment section) <br />COMMENTS: <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 in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. 91 <br />e <br />Signed x �11�✓l�_ • D Title/Gompeny_L�_ //=fW ,q! 2� <br />Print Name �� ! M tiC/�C IC�� Date �V YJ /, 0 T <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: / S6 A-;. yc 7-7 Ak-C <br />WORK PLAN DATED: C v JLLty 0�C R n,..-, lLl� WV - <br />Application Accepted By �_ V Date Issued 0 7 Area 2 <br />Grout Inspection By�Datoc� L Final Inspection By �Date + /C <br />Destruetion Inspection By Dare <br />COMMENTS I CONDITIONS_(' * t eT r. <br />ACCOUNTING ONLY. i AID# <br />FAG# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK Q I REC'D BY I DATE <br />S� <br />C-57` WC__ -WAIVER_ C-57 letter of Authorization to sign permit" Eng <br />CE REOUES INVOICE <br />