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SAN JOAQUIN COUNTY O IGIN <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' ov. r a <br />UNIT IV <br />WELL PERMIT APPLICATIO �11�29 �a , <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSLJeb <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apD�li atnvs'mpliance with San <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of San Joaquin County /Environmental ISI <br />Well Location �7'1 % oolt R D Cross Street NW ] Jr b/r qb0 City t ,Vn o l� ZI� \ �I Assessor's 3 <br />3 O Parcel Z3g0300 <br />'s <br />Property f�� pp ��77 �t o <br />Owner ��L �DlCI)i��S TETR1 L11V1 Address k�Ox 774 / City �ak�»� Zip SZ6Phone # Za1 6qq JW0 <br />C-57 Contractor �'�" oq d u1ard Df' Ili r' ddress SSQ R 1(�( I R Y 1 S/q Zi p Qke? 3 <br />_ �j4 _ ►�-Ot. City 10 p 7I_Lic#�IO079 _'70?-3?�- <br />Consultant/Sub Cntr (;6A iVI8z, ,Q W6K Address.�2'9 K-90 4s St City Lic # 9S7093 Phone gab yz I big <br />��00 <br />o / 1 o .1 I t <br />GIS Coordinates: X � 46 SI.7�/V , Y IZI 13 4t).tj / W , Township 1 S Range R6E Section _ <br />WORK TO BE PERFORMED: <br />XKIEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER-) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br />❑ SOIL BORING F]OVER-BOREDIAMETER <br />DWELL # ❑ PRESSURE GROUT <br />❑ OTHER GROUT SPECIFICATIONS <br />COMMENTS: <br />Ew-2E�tnvtcite y � <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS mw -g yv w,li- A, 4SVmG6 2"14S-) <br />v/S') <br />,9MONITORING OP -C— /01OLLOW STEM DIA. OF BOREHOLE' (O 1 ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: _ <br />EXTRACTION 6 P'-'— ❑ AIR HAMMER/DRIVEN CA ING T CCN Scl^ldJl� 7�TY' �E OF CASIN �] STE L R VC ❑ OTHER l — <br />❑ VAPOR ❑ MUD ROTARY DEPTH OF GROI' EALS ' ' REMTYP �TO BED <br />AUGERS [I HOSE S <br />-0 <br />07AIR SPARGE/OZONE ❑ PUSH POINT (GP OR CPT)_ GROUT SEAL PUMPED: ❑ Yes;Io (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />❑ SOIL BORING ❑ HAND AUGER GROUT SP IFI TI NS Z QQ►N 11� )rRG w11 <br />✓hw-��3:►�-I Zs' Ew-z le' <br />❑ OTHER: ❑ OTHER: APPROX. B RI G DEPTH LTED TRAFFIC BOX OR ❑ STOVE PIPE <br />CONDUCTOR CASING PROPOSED MO (if YES, list specifications in comment section) g <br />COMMENTS: <br />(b <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 />Regulations, an II applicable California Laws. <br />Signed --�� `� yTitle/Company 5!?ltpew'}'-Z lJW&YVIRJ a�a2�lfE1{ fin/(, <br />Print Name A.,+F Date -r�Zz /a— 8, <br />Jj <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 444 4 r /G� S S d cdtC'_ � Q Q01_I <br />WORK PLAN DATED: � G/ J,^ 3 3 Q <br />APPLICATION ACCEPTED `BY /`� bj DATE ISSUED �S1 (� AREA f4 s9 <br />GROUT INSPECTION BY V I c fs,,A L ill@L�r�7z�c�G-23-o8FINAL INSPECTION BYyl c31uy;,3 G�QY7Yt� DATE <br />DESTRUCTION INSPECTION BY 11 / DATE ' , / <br />COMMENTS/CONDITIONS: - Yty f a I J-1 Lo, Q 7' _ AS -1 jnd �' V►' —Z . <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT CROACHMENT <br />EHD 29-01 11/5/07 WELL PERMIT APP <br />ACCOUNTING ONLY: <br />AID # <br />FAC # <br />PE CODES <br />FEE INFO <br />AMT REMITTED <br />CHECK # <br />RECV'D BY <br />DATE PERMI INVOICE <br />no 3' <br />4a49 q 9 00 <br />383. OG► <br />lC?4 5 I <br />��/nZ <br />5 z8 4 SR# S ? <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT CROACHMENT <br />EHD 29-01 11/5/07 WELL PERMIT APP <br />