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SAN JOAQUIN COUNTY off• � ••c r z Gz ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION - ( �� dt?lephone:(209)468-3449 Fax: (209)468-3433 Web:www.si.ov.org/ehd UNIT IV El -. - JUL 2 0 2008 WELL PERMIT APPLICATION ORIC71N NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Applicati �s_hereby, _ g toqd& uin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin Coan,ty;deye 9g i-r(_r t,ifitl ,tchapter 9-1115.3 and the Standards of San Joaquin CountyEnvironmentalHealth Department. Well Location �JS 1� f b 4 _ Cross Street Roxi� CL -- Cit Clock on q�jaDrj Assessor's �d — - -- — - y --------Zlp ------ Parcel#_ Property r I n� Owner_PV\Ak_`_' 6 4�--_—_ Address 3 MOIYiS'OC C1 __— City S `G'K 1�—. Zip q�o`�i i�Phone# C-57 Contractor yv OO,AW QraO�1��lrA AddresSP-(X60- 33�—_--___ Cit �� Y IS I—_ Lic# � 9Phone_ �I `4300 Consultant/Sub Cntrkex QWWbi� Addres5344kO N.C?O1�QY1sfCc Q ultl(�Cit �lt 10Ck 1o9-(p(o -(o � 4 y ____--___-- Lic#___--_Phone---___—_ GIS Coordinates:X ,Y _,Township —_— Range----------- Section -----—_ _ WORK TO BE PERFORMED: )' ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) ❑ DESTRUCTION(CHOOSE TYPE BELOW) ❑SOIL BORING#_--- —_—_ __ 7jlO�00 ❑ OVER-BORE DIAMETER ----_______ r WELL#_�c�- � �- t �- —__4 H/-4/V W-S ❑ PRESSURE GROUT— ---- _ — *OTHER -----_----_ — ---- — GROUT SPECIFICATIONS COMMENTS: ----------------- - ----- TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ❑MONITORING 14 HOLLOW STEM DIA.OF BOREHOLE - %11 Q MDLTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA:_ o��l ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESSs1s►'%k"f 0 TYPF OF CASING:[I STEEL Sj PVC El OTHER I onoll 0-3V C ❑VAPOR ❑MUD ROTARY--------- DEPTH OF GROUT SEAL ___TREMIE TYPE TO BE USED[AUGERS❑HOSE WAIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_____ GROUT SEAL PUMPED:&Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH .�IIS^30') ❑SOIL BORING ❑HAND AUGER------_--___ GROUT SPECIFICATIONS Pr7r+ko-vi C�'r u�r 1.0 �QV��(11 ►�C, ❑OTHER: --------------- rJ5"7y 1 Y/ 7/ _____ ❑OTHER:________________—__ APPROX.BORING DEPTH _—_� _—___—__ ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING PROPOSED ______ (if YES,list specifications in comment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS 1 hereby certify that I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,and all ap li ble alifo�nia Laws. AA,, u AA Signed —� �� -_ — ------------Title/Company Title/Company_—_ �� �}�---------yam -- ----------- Print NameDate ---�--------------------- -- ------- ---�'i DEPARTMENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: _______ 3 7 5 S �1/1 Un g Y A v 5YI tJ>� ---------- WORK PLAN DATED: U LZe_.2� Z o }--------------- ------- --- — ------------------APPLICATION ACCEPTED ACCEPTED BY --- �b�Clli—�� ShcCfZ3c DATE ISSUED 0� "QRAREA_L4.S3 GROUT INSPECTION BY �I }Vj � }�yr1____ FINAL INSPECTION BYG{ i41L _ DATE 818 DESTRUCTION INSPECTION BY_-- 1 cJJ j DATE_ COMMENTS/CONDITIONS: F'�J ) l�1e115 V V./-4 an-a7_VW-S. ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE -E# INVOICE 35- 3 z 94,a 0 3 8 3.o 0 36 8 9 8 SR#1005,f _ C-57 ___WC ___ ---WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT,.-,- ENCROA ENT DOC EHD 29-01 11/5107(WEB) WELL PERMIT APP