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;918 879 2422 # 2/ 3 <br /> 10-23-08; 10: 52AM; <br /> 4�IN SAN JOAQUIN COUNTY <br /> oto. .. ... co <br /> 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 sigov.orglehd UNIT IV <br /> �I FO>T <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. Assessor' <br /> Well Location /V0?j,( 1 11,12• Cross Street A'ep�f�- _-City _�7 ro�r'k�Zip 9'5'3.3 Parcel# .3 33-32 <br /> Property 4 PNL/. - r <br /> Owner_ Address < Q� /y���'� �� _ city_ - _ ZIP. Phone# <br /> C-57 Contractor Wl�G �O Address 95�O Law )V-935 City 2GLW0-1;-- Lie#28339Phone eot) 8733073 <br /> Consultant/Sub Cntr 1/`1CSW✓j2 Address ab'?OC•rxf QA(u or City Uc# Phone 9/Yi 67`7-2000 <br /> GIS Coordinates:X 'y ,Township Range Section <br /> W K TO BE PERFORMED: <br /> NEW WELL/BORING(CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER') ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> C3`OTHER LL,,be- GROUT SPECIFIC/AITIONS <br /> C0MMENTS:.3 6�d�'�N mOtar�'DW'ta we-Ls 4,P1�7 ��COL-Oh ant P-77P�r�G KRIfirAa-' 0227" <br /> J <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORIHG ❑HOLLOW STEM DIA.OF BOREHOLEI0 qtr ❑MULTIPLE CASINGSKMULTI-LEVE�,L,�WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL dr <br /> PVC [I OTHER <br /> ❑VAPOR )MUD ROTARY DEPTH OF GROUT SEAL�t! -f — TREMIE TYPE TO BE USED�0_AUGERS I]HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPEDPeYes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> ❑OTHER: ❑OTHER' CONOUOCTO CASING PROPOS I l7'? 30/ r[ B STEDP RAFUI-ngBOin�XmOR1sO STOVE PIPE <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby ce t I have prepared is application <br /> �nfd that tt'heh ork will be done I accordance with San Joaquin Cou�ntyy Orrdin`ance%Rules and <br /> Regulatlo ,a 11- II ble Cal or `y l�iJ G/2iG�v l �l �O !'!'�///lilC-u <br /> /i�r Title/Company <br /> Print Name �'t O�P?l�i�Q �' ` Date <br /> nn, <br /> ^, <br /> DEPARTMENT USE ONLY 44 , <br /> SITE MAP IN UNIT IV FILE,ADI F�0 )2oP k /r° — 6 <br /> WORK PLAN DATED: <br /> APPLICATION ACCEPTED BY . DATE/I`SS�UE.D,,��d d AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY I`T^'"' -` .DATF4 <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 PERMITISERVICE# INVOICE <br /> cc' 2ss <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> WELL PERMITAPP <br /> EKD 2401 1115/07(WEB) <br />