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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> MITIGATION <br /> Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNIT IV <br /> fns _ <br /> i; WELL PERMIT APPLICATION <br /> I' 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 /> 8(e DID TMbr r\'bA Rd. Cross Street QGt V 1 S R o Q Assessor's <br /> Well Location <br /> � city Stocw^tpr� zip ZogParcel # oa21 <br /> 012,41019 <br /> Property <br /> Owner Cowcophilli ps Address9ty Br'octcl LA7qu City SQ cra rA[A 'l <br /> p 7jpLG`8 10 <br /> o Phone # 9l(o - SSS - 4 (i33 <br /> C-57ContractorrdSCgdt 061tAq Address3t/ 32 OmeC CirClf City2ancho Currt'o,�doq 42Lic # '411510 Phone � I �qle <br /> Consultant/Sub Cntr 51�Ar fl? C- Address3D14 K411ore Rd Sf. loO CityP4imiek ev.dovm Lie # Phonecll f0 - 19 a 1)4[Xl <br /> GIS Coordinates: X Y , Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) ❑ DESTRUCTION (CHOOSE TYPE BELOW) <br /> ❑ SOIL BORING# ❑ OVER-BORE DIAMETER <br /> ❑ WELL # ❑ PRESSURE GROUT <br /> ® "OTHER 6 0X44erl Spa VaP wetly Cas -! GROUTSPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [IMONITORING ]HOLLOW STEM DIA. OF BOREHOLE B &( ❑ MULTIPLE CASINGS ❑ MULTI-LEVEL WELL CASING DIA: 2.'f0 EXTRACTION -❑`AIR HAMMER/DRIVEN CASING THICKNESS SCIn LID TYPE OF CASING: ❑ STEEL kVC ❑ OTHER <br /> ❑ VAPOR ❑ MUD ROTARY DEPTH OF GROUT SEALIfs' TREMIE TYPE TO BE USED ❑ AUGERS OK HOSE <br /> XAIR SPARGE/OZONE ❑ PUSH POINT (GP OR. CPT)_ GROUT SEAL PUMPED:AYes ❑ No (NOTE: MAXIMUM FREE-FALL DEPTH IS 39') <br /> ❑ SOIL BORING ❑ HAND AUGER GROUT SPECIFICATIONS NeA} eeme ht <br /> ❑ OTHER: ❑ OTHER: APPROX. BORING DEPTH LL PJf ❑ BOLTED TRAFFIC BOX OR NaITOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES, list specifications in comment section) <br /> COMMENTS: I44e VQCt 0.genCN 0.DO rOVg � 4u4uSt ISr2o08 <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 /> Regulations, nd al//llIa� pplicable California Laws. <br /> Signed M.��1�! � . ' ~ If'' Title/Company S"I•A-f F SCl e Aft g} , S'I"'ef n + e C <br /> Print Name ftm G e r V . n 1 C Fre vis Date lo 1 S 02s <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: S(,OG `�(n.or ,-}ev�/rta� STKN/� L-oP S, ¢ - 2-� 1 <br /> WORK PLAN DATED- l.a6 15' ZAO rr S � -� 'v L LD"L <br /> APPLICATION ACCEPTED BY DATE ISSUED fD / AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY 11 'L A C4, DATE / I c <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTSICONDITIONS: LvA <br /> ACCOUNTING ONLY: AID # FAC # <br /> PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMITISERVICE # INVOICE <br /> 3 sol ? moz y Ahi� SR# 60 M1I <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 <br /> 3� s ' � 6 WELL PERMIT APP <br /> 3563 3/S Sem DoSS �II <br />