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Mill <br /> r FILE COPY <br /> SAN JOA'QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> " ED SITE <br /> _ 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209) 468-3449 Fax: (209)468-3433 Web:www.sogov.or /q ehd <br /> 1 2008 UNIT IV <br /> '</ Q <br /> ENVIRNWENT HEAUN WELL PERMIT APPLICATION WD 2— <br /> o� <br /> PERMIT/SERVICES 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 San Joaquin County Environmental Health Department. <br /> Well Location O 8ecc�.r,LST-�s Street I V aCi 1 v . Cit n M Assessor's <br /> y�VNG Zip qJ � Parcel#Q (?��1 — <br /> Property A � j 7�% s�yyM �I Q�•. 63 Phone# q2J" I <br /> Owner 0 s �(� �.�. d ess(ppQl p fI,l�,l.�'' 1Ay�1.11M I�Clty �i Zip c'� <br /> C-57 Contractor16S.- 1 Address 2Z0 AJ. nprL-C++ Iy City Zip �Lic#e02331_I,Phone`5-VI i& <br /> 2424 <br /> Consultant/Sub Cntr ._1 Address 2101 WCX/S'i[:/ SI• ltf/il�y0z t4d <br /> c Lic# C GP�hone 5(0 (Ap �L'{.3 <br /> GIS Coordinates:X-12.1,43 81 G W,Y 3-4-.-13(6 /'�1J,Township L- U� Range J �r�Section <br /> WORK TO BE PERFORMED: <br /> ❑ NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") XDESTRUCTION(CHOOSE TYPED——' <br /> ��SOIL BORING# //JJllaa����(,','VER-BORE DIAMETER <br /> N,YVELL# <br /> El PRESSURE GROUT <br /> EU OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS71 <br /> )§ vONITORING ❑HOLLOW STEM DIA.OF BOREHOLE �['�� ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS S • D TYPE OF CASING:❑STEEL XPvc ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL�� TREMIE TYPE TO BE USED DCAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑`Yes XNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30')) <br /> El SOIL BORING El .HAND AUGER GROUT SPECIFICATIONS � = P0V t L 0LKI —&/&C <br /> ❑OTHER: _ ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR XSTOVE PIPE <br /> '.w^'' CONDUCTOR CASIN PROPOSED ..� (if YES,list s^^-"� 4 in commenj,sectio <br /> COMMENTS:l� �.S`�12 ch,An— �2 dl►1� xn � SCI•IQ l �7 �uSL P <br /> i <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,and II pplicable Calif or to La`/ /� XSigned l/"�/to l Title/Company Pro I QL� GGo log iS� �.3�Q�i <br /> Print Name LLAk Date 4/30/via <br /> /DEPARTMENT USE ONLY <br /> p <br /> SITE MAP IN UNIT IV FILE,ADDRE S: o0 U (�, i:i!�-c� •-c- "'�li ��^�7 ����� <br /> WORK PLAN DATED: JO'Oa p <br /> APPLICATION ACCEPTED BY DATE ISSUED AREAD <br /> GROUT INSPECTION BY FINAL INSPRE <br /> pCTIO <br /> /N Y { � D DATE d <br /> DESTRUCTION INSPECTION BY DATE !�8 f v 16 Lb AV Ad2s. <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT V ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />