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0 SAN JOAQUIN COUNTY <br /> '•.OG <br /> ?, ENVIRONMENTAL HEALTH DEPARTAT SITE <br /> ` 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www-s' ov.or "� \`; U �'T IV <br /> �- <br /> WELL PERMIT APPLICATION <br /> AUG 2 G Z008 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> "is,a" '"�i i11 i t_,,- :i TIH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This app�dt[or s'tnadt i.�-,Mt I�hce with San <br /> Joa uin Count Dgyelo meat Titl c�iapt y,� 115.3 and the Standards of San Joaquin County Environmental Health Dep�Ilrnb t.I i S'_t"�/ I -� s.� (X,, <br /> q y h C p'LNtD� ��'�`�� I Assessor's <br /> Well Location �AVis K o K Wl Cross Street k,dlle_ny% 1 R01 City Loll Zip Parcel# !� Zf <br /> Property o3i W au h on A City 54c ck,fan Zip 5.V5 Phone# (�)t 300( <br /> Owner 50.1 )OaQV�O CNr%4/ Address I g <br /> C-57 Contractor QrC tOn SDLP�'I n� Address oti3_65 W��0.(Y1 D(' City S-}ci C k� o� Lic# (73 M�Phone 6,�o '�b 5- $Vol <br /> ConsultantlSub Cntr��j Y.$ Address�W RtsearGh PD,,k City L>OkS Lic# Phone �53a 5(,-5g0-' <br /> GIS Coordinates:X 'y Township 3 N Range 6E Section <br /> WORK TO BE PERFORMED: DESTkU <br /> El NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑OVER- OR TION <br /> DIAMETER TYPE BELOW) <br /> ❑SOIL BORING# <br /> (�WELL# ,AQ' 1 RES E GROUT <br /> ❑"OTHER / GRO T S ECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> y <br /> MONITORING �HOLLOW STEM DIA.OF BOREHOLE aft [I MULTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: t <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 0Sth TYPE OF CASING:❑STEEL JM PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL � a5 TREMIE TYPE TO BE USED❑AUGERS E[HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:MYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> C1SOIL BORING ElHAND AUGER GROUT SPECIFICATIONS 3 -5)!!- BP. 4 o 9111.e CQ(M"i M-A <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH SO) n BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and all applicable California Laws. <br /> Signed oCti 9�� Title/Company I n CCf o AS Gi GS <br /> Print Name La Va'!G� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: ( ✓ 7 /j, <br /> WORK PLAN DATED: Z_0 b <br /> APPLICATION ACCEPTED BY DATE ISSUED 6 AREA <br /> GROUT INSPECTION BY ^�, FINAL INSPECTIONS 1'L [b D 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 /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TOS PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> EHD 29-01 11/5/07(WEB) <br />