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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />VI))600 East Main Street, Stockton, CA 95202-3029 Z <br />u - eOhone: (209) 468-3449 Fax: (209) 468-3433 Web: www.siqov.orci/ehd <br />APR 1 4 2008 WELL PERMIT APPLICATION <br />ENVIRONMENT HEALThoN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />_SERVICES Application isPFIetg4ITIaue-to oari 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' Well Location a.1 .51.4 ffy 9: Cross Street C(SACorn‘l A SkPeet City S-NoCk.i,,,, Zip citu) Parcel # ,39 —o5 Property, <br />Owner .1411-4'v Address ZOO k Ut4/tfi, Si- • /430 C> City S•f-. Zip gif12.), Phone 44110 cal .4o53 <br />C-57 Contractor Cr.A.C.c..de- tir.111 Address .103 -2.- o>bicc. Ch-t-it City )14ncLo 6con-Aati,.., Zip "rl4z. Lic # 7/7S-10 Phone <br />Consultant/Sub Cntr Art,, A 5. Address 4150 C . Gle4n City Lic # Phone6 AO 1 0-79 <br />GIS Coordinates: X , Y , Township Range Section <br />WORK TO BE PERFORMED: <br />I=1 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) CI DESTRUCTION (CHOOSE TYPE BELOW) 1:1 SOIL BORING# El OVER-BORE DIAMETER <br />WELL # PRESSURE GROUT <br />11 *OTHER <br />COMMENTS: <br />DIA. OF BOREHOLE .7 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA I " <br />TREMIE TYPE TO BE USED 0 AUGERS <br />APPROX. BORING DEPTH \S-0 - BOLTED TRAFFIC TRAFFIC BOX OR 0 STOVE PIPE <br />COMMENTS: _ <br />CONDUCTOR CASING PROPOSED I YES, list speciticati ns in comment sectio <br />(.41k,6<kfr/c gm./3 efg, <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PER IT ' <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, and all applicable California Laws. <br />Title/Company cee..44;s1+ ,4roctc.L'S <br />SITE <br />MITIGATION <br />UNIT IV <br />GROUT SPECIFICATIONS <br />TYPE OF WELL <br />El MONITORING <br />0 EXTRACTION <br />VAPOR <br />AIR SPARGE/OZONE <br />rkSOIL BORING <br />0 OTHER: <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1:1 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN CASING THICKNESS <br />0 MUD ROTARY <br />0 PUSH POINT (GP OR CPT) GROUT SEAL PUMPED: es 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />0 HAND AUGER GROUT SPECIFICATIONS 5 "))3 52itt1 — Gzen<r)A- &t.4- ill v. re_ <br /> ETHER: <br />O TYPE OF CASING: 0 STEEL N.PVC 0 OTHER <br />DEPTH OF GROUT SEAL <br />yi <br />SO <br />.44-er <br />Signed <br />Print Name I Date q Oak <br /> <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 39Z 5 bt+c--c,, <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />ACCOUNTING ONLY: AID # FAC # <br />---; --.,, <br />5RDD 539 1 <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE NVOICE <br />__ ..._ 0 c" o 5.-103 .s-- (k_ qii 5-jor sR# 531(9 <br />57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />FINAL INSPECTION BY LI DATE <br />DATE ISSUED 41 i/ AREA <br />DATE <br />EHD 29-01 11/5/07 WELL PERMIT APP