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06/12/2008 09:43 916-92293 MW SACRAMENTO If PACE 02/02 <br /> 06/11/2000 WED 15:05 PAX 2 63433 51TC Eno 4002/002 <br /> V F,LJ/eV U, hVa IL; Go 'A, enu iyVuv" 4 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468.3449 Fax:(209)468.3433 Weir. www.sjgov.org/ehd UNIT IV <br /> c <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applbation is hereby move to San Joaquin Counlyfor a Derma to eonstrum andror install the Work described. Thla applleatlon is made in compliance with San <br /> Joaquin County Dwelopmenl711s,Chapter e-1118.3 and the$Iandands of San Joaquin County Environmental Health Department. <br /> AssesBo a <br /> WELL coaasrreet Olv gave, cuv �CAp9fi&rS Pareew�f�3/o4b <br /> 3910 Ar. Crr7rs,de.Avte- <br /> PROPERTY l:�. tPre. LA <br /> OwnergarEWAW'.lfae.dSt$aeel Address Iq'.SLAler4r,6"L. CiN_ r�_2ipg5EdSP6onaA��o9] g33 Dqf' <br /> G/ <br /> C-57Contfactor AS= b;,11=1 Addreas'W 4d$aS7" 57.. CityJeo6 SOI Zip•t�LiC*gFAMT4Phon1# 61•t I+ <br /> Consultant/sebcntrMWl+ A....,CAIIrowd,Adlrom337aPaws,-=,styS__;WJ0- Lice Phones 4+8- Jg <br /> s <br /> GIs Coordinates:X Y ,Township Ranee Sector <br /> wgRK TO BE PE <br /> ANEW WELL ORIN (CP ,GEOPROBE �ROpUNC ,MWNO-AUGER.OTHER•) STRUCTION (Chaose type below) <br /> DIL �"'r�r'^"J-all COVER-BORE. DIAMETER <br /> ArPRESSURE GROUT <br /> 0 Other GROUT SPECIFICATION$ <br /> COMMENTS: <br /> TYPE OF wELL INSTALLATION TYEE CQHSTRUCTIO SP C!f___�__FNAT-10—Ala <br /> [I MONITMING a HOLLOW STEM DIA.OF BOREHOLP 3' 0 MULTIPLE CASINGS 0 MULTFLEVEL MLL CASING CIA; <br /> O EXTRACTION B AIR HAMMERWIVEN CASING TII CKNESS�,_TYPE OF CASING; U STEEL O PVC D OTHe.R: A.14 L <br /> 0 VAPOR '0 M'U'D ROTARY DEPTH OF GROUT S[AL.. 6Y�. _ TREMIE TYPE TO BE USED:,76ytk1GERS p NOSE l^�' <br /> 0 AIR SPARGE!OZONE w r�SH POW70f CPT)GROUT SEAL PUMPED: Q Yes p No NOTE: MAXIMUM FREE-FALL DEPTH IS 30'I C <br /> .i01L BORINGg HANDAUGER GROUT SPECIFICATIONS Abllrl 7Y.40- lG:4 #V t'f'�uY' <br /> 0 OTHER._ _ R OTHER APPROX.BORING DEPTH !Sr S 0 BOLTED TRAFFIC BOX of g STOVE PIPE <br /> CONDUCTOR CASING PROPOSED dleQ (if YES, IslspeclficadonsIncOmmentsection) <br /> COMMENTS: <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 worst will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Signed r -j,„ilL .L....�%—Wjf,r_..,— rna�co�,pawv 'R�MG✓/ Ame/rrr�Ps.T,vc- . <br /> Print Name /E ill C Cale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /50.5-vJ44;. Wye, ane �n,c tel•L,Z7 <br /> WORN PLAN DATEO:C'I/,w6aC.r'S alLAdtr-r � Ay„ 7i p ( �eeuQQ '/- r <br /> Application Accepted ay OPIe Issued / //A <br /> Groul Inspection By Data Flral InspeGion By Dole/ <br /> Destruction Insp20""'By Date <br /> COMMENTe rCONDITI0N3: VG <br /> ACCDUNTING ONLY; AID# FACR <br /> PE Coo <br /> FEE INFO AMOUNT REMiTTEO CHECK# RECD BV DATE PF.RMITI SERVICE REQUEST# INVOICE <br /> arol <br /> C-57` WC -WAIVER— C•57 Letter of Authorization to sign permit Encroachment doc_,_, <br /> ERD29•dZ.001 . <br /> fr22.ma <br /> JUN-11-2608 01:56PM FRX:2094683433 ID:MWH PRGE:002 R=92% <br />