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SAN .IOAQUIN COUNTY <br /> �- FILE COPY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> Zo <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> ` r_ ephone:(209)468-3449 Fax:(209)468-3433 Web:wwwsigov.org/ehd UNIT IV <br /> �/ [E U WELL PERMIT APPLICATION <br /> MAY 2 7 20 WREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D N <br /> Application is haw1kim i unty for a permit to construct and/or install the work described. This application is made in compliance with San <br /> quin County Di +j 115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> or' Assessor's <br /> Il Location Q .Cross Street�It o I IID j t�LIL �. _ City •�4 h, Zip Parcel# 3�6 04-0 <br /> o /,'. p <br /> Owner Ik-Q �iP_YL� I�itiilG�trtc. Lu,,Address �.Q AD)( Y"4� City �f9 ��'l Zip 20/ Phone#�l� Sc - 72QQd <br /> Y�� t1 r p .5770 Lic# �2ZiQ- Ph3ne b:j. L(,P <br /> 57 Contractor RSI Dy-abnh Address 2'�N. L-ASt 4+re City�.t l0d�owd Zi <br /> l'onsultant/Sub Cntizal. Zt?o�.ZvlGAddress biS J24kr�_ kW City S° joSrt Lic# Phone J x31 <br /> S <br /> JCoo <br /> rdinates:X j•.q SS, r ,Y f 't I t JZ Z Township Range Section <br /> ORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# LU-I 3 IIA - � U 1A 1-*Z ❑PRESSURE GROUT <br /> "OTHER GROUT SPECIFICATIONS <br /> �OMMENTS: <br /> kPE F WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 11 <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2— ❑MULTIPLE` �CASINGS[IA:MULTI-LEVEL WELL CASING DI <br /> EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING:❑STEEL 0 PVC ❑ OTHER <br /> VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREWE TYPE TO BE USED jkl AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE M PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes X No (NO,TE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING C1 HAND AUGER GROUT SPECIFICATIONS —W,4 10-1'^,4Ce i&e4'I <br /> to OTHER: _ El OTHER: APPROX.BORING DEPTH QQT ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Est 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. T 77 r 9 <br /> Signed �"'� " �� Title/Company LJTIy-9'A M 1e1eLt c.L (�-LI t��2Q lr L ,�k le`vr <br /> Print Name _ ` r -4 C'ki Date O 1- <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES <br /> ' WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY i;m AREA <br /> ' GROUT INSPECTION BY FINAL INSPECTIONDATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMM ENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED HECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> ' s•z7 � R# l <br /> C-57 WC V -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> ' ')29-0/ 1 1/5/07 WELL PERMR APP <br />