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SAN JOAQUIN COUNTY <br /> ' ` <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> f£ <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> '"/ MITIGATION <br /> ,. lephone: (209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ¢ 1a�. UNIT IV <br /> 7 2008 WELL PERMIT APPLICATION <br /> ENVIROMIENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> PERNITZSEf I���� <br /> Application is er by m n 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 /> s15 W. C Vioro �le) S�' y 54��c-�-orl p 9SzoG Pacel#rs��3-o�� ofd <br /> Well Location ss Street Cit Zi <br /> PropertyJn Address 1'%144 <br /> � "}A� ` 1 <br /> �3FOwner y zip � 6 Phone# 0 <br /> C-57 Contractor Pfeci0 n SAwI('l i )I Address 2 it 5 W i r City Zip S Z o 5 Lic# 6U 3 Phone109- Y4s - <br /> $�, 1�,"` yaps F•' G�1 'i cit �e.,��� s1s62o q-tS - ZBB-2003 gala <br /> Consultant/Sub Cntr 0.Y' ny�n ddress R°tea y Lic# Phone <br /> GIS Coordinates:X '.Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> [:1 SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# 7P-1 yam,► ❑PRESSURE GROUT <br /> *OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,> <br /> N <br /> ❑MONITORING y HOLLOW STEM DIA.OF BOREHOLE 5"4 1, ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 54�TYPE OF CASING:❑STEEL 14 PVC ❑ OTHER <br /> A VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL `ftp I TREMIE TYPE TO BE USED XAUGERS El HOSE <br /> AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:;4 Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> [I SOIL BORING [I HAND AUGER GROUT SPECIFICATIONS i <br /> ElOTHER: El OTHER: APPROX.BORING DEPTH 5o�t 9 004 'BOLTED TRAFFIC B OR ❑STOVEPIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifics ns' c-Rnent section) <br /> COMMENTS: — � - / CS <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 a plicable California Laws. <br /> Signed �V G ?sj/n , L� �L Title/Company w Yl(MEQ - l <br /> f <br /> Print Namevx/C�S74� Date 47 I b 6 <br /> /� DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: R 13- S I (/I�otit}-�. ( a-1 <br /> WORK PLAN DATED: �� Zoo�� Ao�aQn��i., �l /i1dg <br /> APPLICATION ACCEPTED BY f o�,� DATE ISSUED p AREA <br /> GROUT INSPECTION BY V\e (M�f/� FINAL INSPECTION BY ��pc DATE�O& <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 /> 2`101 K`i,vo SR# 5` 60(> <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />