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. . 0 SAN .JOAQUIN COUNTY • � 1r ILE COPY a� J i.�� ENVIRONMENTAL HEALTH DEPAI SITE =' 600 East Main Street, Stockton, CA 95202-3029 MITIGATION +• •� Telephone: (209)468-3449 Fax:(209)468-3433 Web: MAY `2, 0 208 UNIT IV WELL PERMIT APPLICATI6P�IR`�NME.NT HEALTH ERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development T'tle,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. #-,t O. Assessors p Well Location Cross Street -Tn V7bs. DCity _ Zipg G Parcel#�- T Propert A'Ve, OwnerLA' off- 'PpVa� Address aS9 � 4J'1i mol city ,IFS Zip�53&(o Phone#(c?fl)599'916$�' C-57 Contractorw_L ETnI oYc�Y�rAddress d r I HPp Nle City S..\L.InVYIOVt� ZipA19WfLic#9573 32f0 Phone 090,236 L7 S,-2— Consultant/Sub Cntr'(zo.5ourrp broe Address-5V,51-C—. Eck, City S_IP \Lic# .— Pho,,fWS79r/e/ 93-(. / U / GIS Coordinates:X/,3 f° 83//3 , W,Y nj� o- 7Jr. O 09N,Township n lh Range Al/4 Section _N (•- WORK TO BE PERFORMED: ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) [I DESTRUCTION(CHOOSE TYPE BELOW) SOIL BORI ElOVER-BOREDIAMETER WELL# # ❑PRESSURE GROUT ❑"OTHER GROUT SPECIFICATIONS COMMENTS: TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS V1 MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 9' ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS SC jn'q0 TYPE OF CASING:❑STEEL 0 PVC ❑ OTHER ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 1.57-XIS' TREMIE TYPE TO BE USED FkUGERS❑HOSE ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:gYes [I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') ❑SOIL BORING El HAND HAND AUGER GROUT SPECIFICATIONS 1✓ d Y 14-11,p /A CC / 0�./ []OTHER: 'A OTHER: Jbh i r' CONDUCTOR APPROX.BORING DEPTH p.fsOLTED TRAFFIC BOX me []STOVEPIPE CONDUCTOR CASING PROPOSED (if YES,IIsi specifications in Wmment section) COMMENTS: NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS 48 WORKING HOURS.NOTICE REQUIRED FOR INSPECTIONS 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 Regulations,and all applicable California Laws. -T Signed f�//�—� )Y� _Title/Company'jf- 7 �QA I'�'- Sn.,t,n Ein --1-NC. Print Name et�i,2 //71G.JD,%l Date p DEPARTMENT USE ONLY p n �] SITE MAP IN UNIT IV FILE,ADDRESS: / 3 2— I 9 3 G FY'DYI-'�"Q; e- !l0 � I iFJ6Y1 L_LT WORK PLAN DATED: M is V / Z fZD 50 �J �ry APPLICATION ACCEPTED BY V/ L:'4 DATE ISSUED 51.2 110 8 AREA I�S-(_ GROUT INSPECTION BY V j'&tDNb L. t4& Lbz4i FINAL INSPECTION BY te&efa ( DATE L R•oR DESTRUCTION INSPECTION BY L (� DATE I ` 9 COMMENTSICONDITIONS: r+yLSIA,)I@+I All n'r ZS 'IULJ dI7d 2�2 Y170440.1-) Q" llll%/�f IrL +he CJ of ftleart ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# I INVOICE 2907 789,0069.00 32824 LImL 1671.wlos I SR#05430 C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC EHD 29-01 11/5/07 WELL PERMIT APP