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J` <br /> SAN JOAQUIN COUNTY F_)) -rc� <br /> ENVIRONMENTAL HEALTH DEPA L <br /> RT�Alq SITE <br /> lot * <br /> -0. <br /> 600 East Main Street, Stockton, CA 95202-30 20 <br /> 08 MITIGATION <br /> L <br /> 9h <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web: /e <br /> V.Org d ' . UNIT IV <br /> 4_NV1R0NfM1[Nt HEAL <br /> WELL PERMIT APPLICATIO pp` <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 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 <br /> Joaquin County Development Title,chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> STt>_ Assessor's <br /> \L <br /> P4 <br /> Well Location(0(15'ts ?KCkT--kC 1�16 Cross Street tOCT t�a_ City TOZip Parcel# 04141 o`} <br /> Prope1'ty6%Cv%t*._i (0111 &LAA"Ci CI— <br /> I-rori <br /> Owner Mpii-,yj+L_j0mrjj C&w%9&%q_ Address PEP, 9-. 3(151L Cit P-A*4 cnj <br /> Zip Phone# <br /> C-57 Contractor ascAwr bo,.U.6 jj� Address 3432- ciry\ec, Cie- City&NWAp (Mou A Lic#117:510 Phone 9/10-(-319. 114 q <br /> Consultant/Sub Cntr_AfLPfD).<, Address LSO 6,C-rjA N9,5TE 12-s- city Lic#_Phone1?14J1f55. Z-07'1 &?_0 <br /> GIS Coordinates:X 10 , 12-1. 31-1 <br /> Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Ej DESTRUCTION(CHOOSE TYPE BELOW) <br /> J8 SOIL BORING# El OVER-BORE DIAMETER <br /> El WELL# 0 PRESSURE GROUT <br /> El*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [__1 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE-1-' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:El STEEL 0 PVC 0 OTHER <br /> El VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL'`55 40 TREMIETYPE TOBEUSED E]AUGERS E]HOSE <br /> 0 AIR SPARGE/OZONE 91 PUSH POINT(GP OR CPTC]?7 GROUT SEAL PUMPED:IkYes [I No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q(SOIL BORING El HAND AUGER GROUT SPECIFICATIONS Oeme-r- Ze..7.0 ar. 610,,r To 5,K FACE 1x6r.\%r.D <br /> 0 OTHER: El OTHER: APPROX.BORING DEPTH SS -t40' 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED — (if YES,list specifications in comment section) <br /> COMMENTS: ID11tc-oT Poco 60g I N ri C-Ir .Sat, SlsrApUes <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 red this apy2caliQU and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and-all applicable <br /> Signed . �_F - , Title/Company C-c-IJ I Ct A-(,A sT <br /> Print Name J. Vj A,L4__ Date - 0% 1 <br /> DFXARTMENT USE ONLY C V F-Ld a C312,1.57- <br /> SITE MAP IN UNIT IV FILE,ADDRESS: W,� <br /> WORK PLAN DATED: -5• 2z o J?_ <br /> APPLICATION ACCEPTED BY DATE1 u ED 9- AREA <br /> GROUT INSPECTION BY FINAL INSPE( 7, • DAT <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 /> 2,4?1 • <br /> 0,372 SR#aj53 3 � <br /> 57 V WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07(WEB) WELL PERMIT APP <br />