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SAN , OAQU;NC6UNTY ` FILE COPY ENVIRONMENTAL HEALTH DEPARTMENT SITE 600 East Main Street, Stockton, CA 95202-3029 MITIGATION L 4one: (209)468-3449 Fax: (209)468-3433 Web:www.sioov.org/ehd UNIT IV 1608 WELL PERMIT APPLICATION '� t( �/ WLb fiLr ON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O 1� CC 1� DCir,,�......-.)=r�A1 564r Application is fieYeb�j ih�`d��tb`S9k laeaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's Well Location FkZ.S 4L bOdA-ttD ST Cross Street MR TNEwS AD h'):) City F4E,d CN c*4P Zip9 .231 Parcel# ��Q Property Owner CVcc-#,h ✓AL`0 d:2- Address r��J ljitT city FREA1cH cAwP Zip 95,13 i Phone# Z C-57 Contractor 4160160ARb Address SSo )EVICR ROAD City Rla JISTA Lic#7Joo79 Phone 70737-1"y3400 Consultant/SubCntrF� -'ZrOC 717 Address 1117LON5 PALry 4✓E City rMoaK>a Lic# Phone 2Z>9S792Z21 GIS Coordinates:X 31i I Y —12-1-2-76 ,Township Range Section rK TO BE PERFORMED: EW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) [I DESTRUCTION(CHOOSE TYPE BELOW) O(' ❑�SO IL BORING# ❑OVER-BORE DIAMETER 1 2 WELL# 7407 20 — -rL rw 2 ❑ PRESSURE GROUT ❑-OTHER -7 Q ! baa SPECIFICATIONS V COMMENTS: /IfUI;e ^' J D Io{o .7� / Ya —LO ay ba TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS MONITORING l -40LLOW STEM DIA.OF BOREHOLE I T�t ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: .Z H ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SCH 'to TYPE OF CASING:❑STEEL PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL V ARr A6(.6 TREMIE TYPE TO BE USED❑AUGERS❑HOSE O ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:Oles ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') El SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS YO,f.T4AN, CEwENT J+SDUC ❑OTHER: rr ❑OTHER: APPROX.BORING DEPTH !o S- /4'D BOLTED TRAFFIC BOX OR ❑STOVE PIPE p `r/9�ciun`P,RROOPOOfSED / dE.0-_. V YES,list specifications in comment section) �pOQMME 0 5 e �^^ „Z�rS/�dr l��ry / �P. �@ ��4 9 Gyj NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS I hereby c -Ahat I have prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and Regulations,an�ft->pplicabl C ornia Laws. Signed �- — Title/Company 7.LoFFSSioo--�L C�6f]�or'i-�i Print Name —70�z� Q/ DEPAR MENT USE ONLY SITE MAP IN UNIT IV FILE,ADDRESS: O r 2-5 S .— CFP WORKPLAN DATED: APPLICATION ACCEPTEDBY y AREA B GROUT INSPECTION BY FINAL INSPECTION DATB/ Q / DESTRUCTION INSPECTION BY DATE COM M EN TS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE Z�IO 95 —I•q-C8 R#=5 56 C-57 WC -WAIVER if C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC WELL PERMIT APP EHD 29-01 1115/07(WEB)