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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.orgiehd <br /> <br />SITE <br />MITIGATION <br />UNIT IV <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 compliance with San <br />Joaquin County Development Title, chapter 9-1115.3 and the Standards of Sen Joaquin County Eryironmentel Health Department <br />/OW fm• <br />Well Location 1 S"35 Tkov-r.41,1•N gd 'Cross Street k I'm L e-a_ City 5 .1-vc-141T-44 Zip <br />Property ..%.‘o vile% 'F. k.,•••• \-4 <br />Owner a cub tt -t-,-yç- <br />C-57 Contractor V 4-V3 t)r', \l'9 Address P.°‘ 1?:0-1: 9 -70 City 2--0 8 ; zip c". 5 7 `1/ Lic * 7 1 ph3oggtIIr vo <br />Consultant1Sub Cntr t7 -'V Address 17 iq .4^0•; " 5 + • City ëc ca1/01--.. LIG* Phone c7 gEr <br />GIS Coordinates: X • Y , Township Range Section <br />WORK TO BE PERFORMED: <br />0 NEW WELL/BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHERS) DESTRUCTION (CHOOSE TYPE BELOW) AA L'i 1 t AS- <br />0 SOIL SORING# OVER-BORE DIAMETER 6- ., <br />ID WELL # J PRESSUREGROUT <br />0 *OTHER GROUT SPECIFICATIONS 4,1,(Arta.. <br />COMMENTS: <br />Assessor's <br />Parcel* 0-11-`-+ '1 0 -4 .7 <br />Address V• • (3 eX, 040 Cityi:•ear. Zip `Z 5 Phone* ?o'- 3 4, 7- tz qZ <br />TYPE OF WELL <br />O MONITORING <br />0 EXTRACTION <br />0 VAPOR <br />0 AIR SPARGE/OZONE <br />0 SOIL BORING <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />0 PUSH POINT (GP OR CPT)._ <br />0 HAND AUGER <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE e'r 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DiA: <br />CASING THICKNESS 1iA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />DEPTH OF GROUT SEAL (D /11 I I TREMIE TYPE TO BE USED AUGERS D HOSE <br />GROUT SEAL PUMPED.'K Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS Ai e-0,4- Ccevv4 .4 G- <br />0 DI 0 OTHER: APPROX. BORING DEPTH 0 BOLTED TRA;'FIC BOX OR 0 STOVE PIPE <br />COMMENTS: /4414h 4i- CONDUCTA,114,5$1N3 PROPOSED . (if YES, 'hi varnment secilon <br />6.41,) • _A-Prif, C On-4 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I have prepared this application and that the work will be done !accordance with San Joaquin County Ordinances, Rules anti <br />Regulations, and all applicable California Laws. <br />Signed L1A.— Title/Company $4•°,•C'' r7: <br />Print Name 3 .e... \JcArs7 26-•-- <br />DEPARTMENT USE USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: //e0 .tv‘ 40,hi 4-4,N, 404,4_ <br />WORK PLAN DATED: <br />APPLICATION ACCEPTED BY, <br />GROUT INSPECTION BY 90 <br />, ACCOUNTING ONLY: AID ft I FAG* <br />PE CODES ' , FEE INFO AMT REMITTED CHECK # I RECYD BY DATE PERMIT/SERVICE # INVOICE <br />"3c0-t- &O- ‘0` D/770, /..1-&-- Wz//ot SR# 04Ar yi.,et 2, <br />treo`io?;S-f. <br />Date 3/0 <br />FINAL INSPECTION <br />DESTRUCTION INSPECTION BY DATE Co 12:7 <br />COMMENTS/CONDITIONS: tOP ç : — 04Ah/ 7 c d-v-e.A.ceLati YLv'AjcfC <br />Te"o /1 pled y gi'S <br />DATE ISSUED 4*/ Olt AREA <br />DATE 6/.2-7/0i <br />C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br />EHD 25-01 11/5/07 WELL PERMIT APP <br />6 4447