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"4 I <br /> an Joaquin County FILE COPY <br /> z Environmental Health Department SITE <br /> . s ' <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> . �.; <br /> !i(,00)4693449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT 11/ <br /> Well Permit Application <br /> X08 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is h rgby'fade to at iloatifiIj-ppnty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Deye'Ika rN Fi IftiGha tgr 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> ` ' �_` Assessors <br /> WELL Location /$ e^17It1411i e)at, Frl Cross Street Mission k'nael City 4_hyk-fan Zip �S q_Parcel# /_?.3 -1N <br /> PROPERTY <br /> Owner pki L-Ia1 `,' Address 18a�('/uA Airwitiao City .S&kip n Zip�^ Phone# Wcl-1 <br /> C-57 Contractor Rcty int,.r l PL(nu;ron xthJif tic Address ?3­7 ,4hcrt�� Pocvrl City gbf kfawL • Zip_ Sirs Lic#(A o-�)a-7 Phone# -vG 7 laetr <br /> Consultant/Sub Cntr RdUonel<l L.'61'nwrtnmrn6 ,•� Q,1n— X3'7 Address 4harr,� i�nQcl Cit <br /> Y �inrt-wn Lic# L&D�'�1 Phone# De. �lu-7-/rlOi, <br /> GIS Coordinates:X 37-•%_ ,Y-12-1• / Township Range Section <br /> WORK TO BE PERFORMED: <br /> -kNEW WELL/ BORING (CPT GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other 3V/- l/7 GROUT SPECIFICATIONS <br /> COMMENTS: &)Ovk acfn rrlat<t'ct 4S /-fay -26oR _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLEU a�L" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA _ "IA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS !J!R TYPE OF CASING 0 STEEL 0 PVC 0 OTHER. <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ,rj' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes &No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ;g SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS :EpPc S/IIbrl Irirnc` 000en+ <br /> 0 OTHER._0 OTHER APPROX.BORING DEPTH S` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Nib (if YES,list specifications in comment section) <br /> COMMENTS: n•e jfretl& Wotk Plan tlt k-rr I Hatt :1668 <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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed Title/Company Vtei P)-e-D(hr I JI'MUCAn <br /> fir/ rPnfnv`�nntnPri-!a/'lrc <br /> Print Name Robe,-t e rAhl Date cL r n91n8 <br /> DEPARTMENT USE ONL��Y <br /> SITE MAP IN UNIT IV FILE, ADDRESS: /BSG -C�Gr��rs, C-✓1.t.4 - ..._ NtM-� <br /> WORK PLAN DATED: :57• F.C) <br /> Application Accepted ByL Date Issued < �+ Area D6 <br /> IRA Ab soudw <br /> Grout Inspection By Date Final Inspection By - ^"t72te <br /> Destruction Inspection By Date <br /> COMMENTS t CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> SR#fir �- <br /> C-5i-VI WCC WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment docAjK <br /> EHD 29-02-001 WEB <br /> 9/11/2007 <br />