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SAN JOAQUIN COUNTY low <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.sioov.org/ed hUNIT IV <br /> WELL PERMIT APPLICATION <br /> ewriro' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WDC <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 /> Assessors <br /> Well Location/61177 ml,, iaipoe ross Street fAlr COUiY6 Ave,, city ZArl"re A Zip f".rO Parcel# /!6- YA9-32 <br /> Property <br /> Owner HAWY f/4&Ar kNGI/DA Address I7000 0. "/ i IRD A/AY City rAley cA Zip ,'U&Y Phone#(4o 831-/Y38 <br /> C-57 Contractor WpC Address 200 <Ovvey ^0 91$City zl'•f CP fig Lic#Z831z6 Phonelp0#8r3•.�7P <br /> ConsuttanVSub Cntr SrAX17We Address POND fill City,tiQrY�IY_ O tatOp Lic# S 4 0Phone 8A/-O r/00 <br /> GIS Coordinates:X. /a-.gIZ ,Y —12t, 2,93 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) El DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING* ElOVER-BOREDIAMETER 1 <br /> 7 WELL# MW-26 VS-4 Vr-2 m SP / SR2 SOS ❑PRESSURE GROUT <br /> 'OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,CLW f VE= 2 <br /> kN-z6 „ o2oNE': Jr/y" <br /> ,MONITORING HOLLOW STEM DIA.OF BOREHOLE � ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA'. <br /> . W+VE= SCH 40 <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESSO?VNr r Self TYPE OF CASING:❑STEEL PVC ❑ OTHER _ <br /> MW= S' V6: Y' <br /> VdAP%R �X=RAc� MUD ROTARY DEPTH OF GROUT SEAL EZ!"Ec/G TREMIE TYPE TO BE USEDAr AUGERS❑HOSE <br /> $AIR SPARGDOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes XNo (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SP-77 SA-5 <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS //EAr ew-.eeLrNT <br /> AW-/7' W P/0' <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH OZ'NE a App 'BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED No (J YES,list specifications in comment section) <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 all applicable California Laws. <br /> Signed A"1 Title/Company 6EO[0Wc cr AI TE <br /> Print Name /C lf" f0aWZ//E.P <br /> / DEPARTMENT USE ONLY �y/J <br /> SITE MAP IN UNIT IV FILE,ADDRESS: p.�6 7 6 <br /> WORK PLAN DATED: "�O'Op C,1/0 iVpp <br /> A" p <br /> APPLICATION ACCEPTED BY DATE ISSUED L O 0 AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 0 D R# AS 0s <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORI TION TO SIGIA PERMIT ENCROACHMENT DOC <br /> EMD 2&01 11/5/07(WEB) <br /> WELL PERMIT APP <br /> FILE COPY <br />