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JUL-21-2008 11:53 E.R.R.G 415395999 P.07/30 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT SITE <br />600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.s'oov.or lehd UNIT fV <br />�s <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 cornpiiance with San <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards at San Joaquin County Environmental Health Department <br />well Woo n Assessors <br />Y�,CfDSS S et City Zip Parcel # -LA to <br />propert <br />0 pY/l p <br />Owner ress ! „ity ZIPhone ( • 1 <br />1 1 � <br />C-57 Contractor ! A dressi b ItoGity Zip Ic # o <br />CortsultanUSub Cntr Address �' S City Lic # bne�� a <br />GIS Coordinates: X Y , Township Range Section <br />WRKTO EPERFORMED: <br />AID # <br />FAC # <br />NEW LL E1ORING (CP , GE P O , H ROPUNCI� HA <br />GER. OTHER-) ❑ DESTRUCTION (CHOOSE- TYPE BELOW) <br />94I6G" <br />SOIL BORING <br />❑ OVER -BORE DIAMETER _ <br />I] WELL # <br />❑•OTHER _ <br />❑ PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />L.2 -t /6 SRZV5, <br />COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />❑ MONITORING ❑ HOLLOW S; EM <br />El EXTRACTION [I AIR HAMMER/DRIVEN <br />DIA. OF BOREHOLE � �n ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: I �� <br />CASING THICKNESS �Q_ TYPE OF CASING ❑ STEEL Ly PVC ❑ OTHER <br />UD ROTARY <br />❑ VAPOR 71P'USH <br />Q AIR SPARGE/OZONE POINT (GP OR CFr) <br />DEPTH OF GROUT SEA! �~ TREMIE TYPE TO BE USED [7 AUGERS [I HOSE <br />GROUT SEAL PUMPED es ❑ No (NOTE: MAXIMUM FREE -FALL DIEPTH IS 30') <br />OIL BO G ❑ HAND AUGER <br />GROUT SPECIFlCAT10NS <br />OTHER O r 47HER: <br />APPROX. BORING DEPTH d BOL D 7RAFFtC t30X OR ❑STOVE PIPE <br />COND=TOR CASING PROPOS: (H YES, I�St apvGir�Oona u� Cantrtrtnl aecvOn) <br />COMMEN S: <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 I accordance with San Joaquin County Ordinances, Rules and <br />r DEPARTMENT USE ONLY j <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED 13Y <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTSICONDMONS: <br />FINAL INSPECTION <br />DATE <br />BATE ISSUED _74llld AREA y <br />BY DATE 7 �� <br />ACCOUNTING ONLY; <br />AID # <br />FAC # <br />PE CODES FEE INFO <br />AMT REMIT-= <br />94I6G" <br />RECV'D BY DATE PE INVOICE <br />Q <br />L.2 -t /6 SRZV5, <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />