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09/16/2008 17: 04 9168610430 SECOR PAGE 04/04 <br /> 0 • <br /> Ht SAN JOAQUIN COUNTY <br /> D 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.sagov.org/ehd UNIT IV <br /> d�oo d <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE PER EXPIRE 1 YEALER2M-1281ILaW99 �}• <br /> Application Is hereby made Id San Joequin County for a permit to construct andler install the work described. This application Is made In compnance with San <br /> Jcaquin County Devalopment Title,chapter 5.1115.3 and the Standards of San Joaquin County Enulronmental Health Department. Assessors <br /> Well 1-009t[012,2—'Zo FbR.Y R•O g&S Crow Street W WA5W"dirb r CRY SYo.x T&" ZIP 1��C- Parcel#J"r -T <br /> W <br /> Property ,v none CI Sr+xy �•+ zp qw�7 Phone#(�L. •4R- a�4L4 <br /> Owner 1-1dfz-n c t m*dX21di Address r w.q,g.4 h r�— <br /> C-67 Contractor l G'iio� Address .363,2. fir• el&— City Fioi✓c� ara4.lo# n@ITonaCQLL>6x�-/16.9 <br /> COnaUttant/sub Cntr SrAAfrcrr-_ Addrew JOA 7 /L L!_^&9 T�'b_ City $/yN ,o cortu04c# Phon l6 � i-AW oea <br /> GIS Coordinates:X 93t YK, Y �-Z� y�D ,Township / Range�SecVon �_, <br /> R TO BEP FDRMED: T+-rJS CLC s r <br /> ttlkkk DESTRUCTION(CH003E TYPE OW) <br /> NEW W��LU ORINO(CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER') <br /> / 0 BORINICT OVER-BORE DIAMETER v <br /> LL# Y J t3j /�- tJ !•V PRESSURE GROUT <br /> THEIR GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CQNETRUCTION SPECIFICATIONS <br /> Ikl MONITORING ❑HOLLOW STEM DIA•OF BOREHOLE _ O MULTIPLE CASINGS E3 MULTI-LEVEL WELL CASING DIA: <br /> I❑•'EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:O STEEL 0 PVC [I OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED❑AUGERS[3HOSE <br /> ❑AIR SPARGE/OZONE C]PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:b Yea ❑No (NOTE:MAXIMUM FREE-PALL DEPTH IS 30') A, <br /> F- <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> OTI+ER: OTHER: PPPROX.BORING DEPTH Q BOLTED TRAFFIC BOX OR ❑STOVE PIPE C-\§ <br /> CONDl1CTOn CAEING PROPOSED Ilf YE9Ibl spodAcaYans In eommeM ew:�k�) .p— <br /> J <br /> COMMENTS: ( <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS (- <br /> 'J <br /> I hereby ceRlfy that I have prepared this appncddOn and that the work will be done I accordance with San Joaquin County Ordinances,Rules and _ <br /> Regulations,and all applicable California <br /> �!7 Tltlelcompany L e*Ao u--nr E7', zap <br /> Signed II' <br /> Print Name % `- <br /> c 'i Date 9-zL"m Cp <br /> /•.r I }S.L� �� <br /> DEPARTMENT USE ONLY 1 <br /> SITE MAP IN UNIT IV FILE,ADDRESS: (,VQ l n <br /> WORK PLAN DATED: <br /> DATE ISSUED AREA <br /> APPLICATION ACCEPTED BY <br /> FINAL INSPECTIO BY DATE <br /> GROUT INSPECTION BY j <br /> DESTRUCTION INSPECTION BY DATE Z <br /> C1A c_Z <br /> COMMENT9ICONDIT10N3: X71 T C' - <br /> ACCOUNTING ONLY: AID# FAG# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'O BY DATE PERMITISERVICE# INVOICE C <br /> IND SR# 60.99 0 <br /> G57 WC -WA ER ` G57 L ER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WEI.L PF-RMIT APP <br /> EMD 2601 111SAT(MO) <br />