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JFJLL=\vJhU v L�,uv9/vt,Y4 • 1 <br /> W ECL I NS i 4LLR-114,) <br /> SAN JOAQUIN COUNTY Do 5 2008 �IL/l{1T #5A1X�IS�lo6 <br /> ENVIRONMENTAL HEALTH DEPA ENT HEALTH SITE <br /> 600 East Main Street, Stockton, CA 95 I E MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web: 9�b u� as UNIT IV <br /> WELL PERMIT APPLICATION <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 /> ,I'Ijl Assessor's <br /> Well Location 740 tA5T//0?7J X44- Cross Street ACK/AILL'�/4ewue City LA-n+RoP Zip R Parcel# <br /> Property DCF:"Ty'v�yN4ls71�5 <br /> Owner_AGE7+P7 / I'kJT� Address ZSL�O CtfIZISM/11� ISD, City n� r Zip�/537( Phone# �9'U33'`k7bs <br /> C-57Contractor C},K444 OM0,01d C) Address 5'S�No wE Rc • City MIHKTUv PSL Lic#96516s Phone 9L5-313 -54. <br /> Z ZO /1 5htZPAASNro <br /> onsultan Sub Cntr L)7-5 fir-!'. Address d1/ ITC' (50 City Lic# Phone ql6 ^67ci^ZZS�f <br /> GIS Coordinates:X Z134443 40 ,Y 63 S7SeZ•�Z- ,Township T t S Range R 6 E Section <br /> WORK TO BE PERFORMED: ��55 <br /> F1 NEW NEW WELUBORING(CPT,GEOPROBE,HVDROPUNCH,HAND-AUGER,OTHER') DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# PRESSURE GROUT <br /> El'OTHER ,, y/p // F GROUT SPECIFICATIONS. <br /> COMMENTS:--��—"—I/ .5� l.��P.(.' t;{ �'�J 3, e F 6; i!`?A- t&z 6 .Yi OS 7 <br /> f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ���� � <br /> 0 MONITORING I-q HOLLOW STEM DIA.OF BOREHOLE 0� �7 <br /> []MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: 1w <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS 5c.14- Ao TYPE OF CASING:❑STEEL A PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL YAIUC'6 TREMIE TYPE TO BE USED❑AUGERS❑HOSE p/C Ii>lPr <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:A Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 51�E A7rl1G+MCtrr <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> f 5 C NQ DUCTOR�,1No PROPOSED (if VES,list sp ra=tions in comment section) <br /> COMMENTS: VrE!-!- ����VG !ON L5�T7'I-�L /H'f�![{,fh Y <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 /> Regulations2d all applicCalifornia Laws. <br /> Signed -� <br /> Title/Company 5jzX11--e/'fZ UfZ5 COP-Pa/LWn0n4 <br /> Print Name (part=-- 7-- P1 -&z$ Date I X-1/40$ <br /> '/yn <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: O p /J/�r�C- t ���� <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY DATE ISSUED r 1 0 l/ AREA?- <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE 416-K l 0� <br /> COMMENTS/CONDITIONS: CC <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES ]FEEII.NIO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> bow <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PER IT ENCROACHMENT DEC <br /> EHD2B-0t 1V5/W(WEB) WELL PERMIT APP <br />