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_ • • FILE COPY <br /> >°PQUiN ro SAN JOAQUIN COUNTY <br /> 2 '? ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> *' * telephone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.orq/ehd UNIT IV <br /> o .� b �' i�lf� �� , � <br /> \sir c I�1��� <br /> WELL PERMIT APPLICATION <br /> MAY 2 7 S 1 YEAR FROM DATE ISSUED � O N <br /> a �!7(�N REFUNDABLE PERMIT EXPIRE ^ <br /> Application is hk"`!6�(�4���IC'�(1jJ i unty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County DQet �$�} �1115.3 and the Standards of San Joaquin County Environmental Health Department. Assessor's <br /> ` Q (} / rersns3in Cross Street J q f}apL�rin U �sf. City J f�J 11, Zip � Parcel# l 6 04'� <br /> Well Location <br /> Property �) { lCityfork,,-OvL zipi, Lo Phone#fi . - 72- <br /> ) <br /> Owner 2 Address cI�?O)669 <br /> C', <br /> �'1 g5-776 Lic# ����� P one 1 L� <br /> C-57 Contractor RSI t�rt 11 in Address 2?XON ASS S�uk- City IAVd� Od ZI P <br /> "k 00,k � Lic# Phone[f." z— �30 <br /> Consultant/Sub CntrzNAj �,15-CAddress � <br /> GIS Coordinates:X t\I 3 1. L ,Y �-� �ZZ Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION(CHOOSE TYPE BELOW) <br /> ElNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) OVER-BORE DIAMETER <br /> ❑SOIL BORING# ❑ PRESSURE GROUT <br /> WELL# M�_ f—�—li��3 i I-�Lt�`�i -- GROUT SPECIFICATIONS <br /> *OTHER <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE MULTIPLE` 1TYPE OF CASING:El STEEL 0 PVC ❑ OTHER[3MULTI-LEVELWELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS <br /> ❑ i VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL I Y�S TREMIE TYPE TO BE USED jt AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes 4 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS Q-4I C)hA jtJA)X k'"4 <br /> OTHER: APPROX.BORING DEPTH 9'f�e4 El BOLTED TRAFFIC BOX OR [-ISTOVEPIPE <br /> ❑OTHER: ❑ 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. 7 ( / <br /> �,� (i{ i" Title/Company r <br /> C-- <br /> v i r�nWt k►1T'c.� " '- `"2,f � ' � 7e�/n <br /> Signed Date c. <br /> Print Name "0"', GL ki <br /> DEPARTME T USE ONLY 9&C <br /> SITE MAP IN UNIT IV FILE,ADDRES : Sv <br /> WORK PLAN DATED: <br /> D � - AREA <br /> APPLICATION ACCEPTED BY ::�n r <br /> GROUT INSPECTION BY <br /> FINAL INSPECTION B -99z--r— DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED HECK# RECV' I BY DATE PERMIT/SERVICE# INVOICE <br /> —2-7 ' R#� l <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMIT APP <br /> 1)29-Cl 11/5/07 <br />