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oc.°•�!N � tri FILE COPY <br /> Joaquin County �(�� r�L�� <br /> r ` Environmental Health Departm°eilt SITE <br /> N• < <br /> 600 East Main Street, Stockton, CA 95202-302MA1' 2 0 2008 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> �9�,Foaa P Well Permit Application ENVIRONMENT HEALTH <br /> PERMIT/S RVICES „ /i <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (J/ <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 /> rQ Assessors <br /> WELL Location Z3GS9 !;&ak Agol Cross Street llenrr .4 re. city ✓•wfsznrk Zip95'367 Parce1#2y9 <br /> L07O/0 <br /> PROPER /� �•p o t �,n �/ <br /> Owner OS• `6&Q Address 2US S,;,r1iIA9 City WprA�y Zip Phone#Gri 9& ��Z•3 y2 <br /> C-57 Contractor V ecntx / Add/dress.l�2/& 4co /61✓al City[OCh&&--Zip9S�S3LiqPhone# <br /> Consultant/Sub Cnttrr 6eacotr[dnw 11" Addddre/sss 471�C'1 Sf Cit Li.# '— Phone# Y,jS-��c�--grw <br /> GIS Coordinates:X 37•TYS Y—17A• L T� Township Range Section <br /> WORK TO BE PERFORMED: <br /> n NEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') n DESTRUCTION (choose type below) <br /> .SOIL BORING#C 9 /U if,/'IL DOVER-BORE. DIAMETER <br /> n WELL# O PRESSURE GROUT <br /> n"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING n HOLLOW STEM DIA.OF BOREHOL A" n MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: n STEEL n PVC n OTHER: <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> U AIR SPARGE/OZONE JXPUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes nNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> XSOIL BORING n HAND AUGER GROUT SPECIFICATIONS Afdi CPIHINf1 <br /> n OTHER:_D OTHER APPROX.BORING DEPTH YO n BOLTED TRAFFIC BOX or n STOVE PIPE <br /> [ CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: r /�M OrYf rrtL .tn fiA��rt Pry&L 41-fd�y urns Li <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 in accordance with San Joaquin <br /> County Ordinances, <br /> ces, Rules and Regulations,and all applicable California State Laws. /1 <br /> Signed x �S�CJ ��/t/1.trYA-�"`� Title/Company 6IL-OCOn Co n•S ( ��ill Irl e. <br /> Print Name L2. r�Iwrit• Date Mz2 t� Z 7i� 0000 <br /> DEPARTMENT USE ONLY �� <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 569 s• D/GoP <br /> WORK PLAN DATED: Aw A <br /> Application Accepted By Date Issued �� -�" Area <br /> Grout Inspection By D e Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER_ C-57 Letter of Authorization to sign permit_Fri n -- -c . - / <br /> EHD29-02-001 WEB t/j�; 1 . <br /> 9/11/2007 <br />