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L) [Eff: <br /> RFL) 1: <br /> %DD <br /> SAN JOAQUIN COUNTY <br /> J ENVIRONMENTAL HEALTH DEPART&W 1 2008 SITE <br /> Q <br /> MUM 600 East Main Street, Stockton, CA 95Q2.3Q29 ,. MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:' °' YLi <br /> �4�fFlORa`F P P1 . i;7 Sr- UNIT IV <br /> WELL PERMIT APPLICATION FILE COPY <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 /> (' 1 Assessor's <br /> Well Location J Cross Street l`(w� City (v4,C%t Zip��3�� Parcel#Z�S 1 ra z9 <br /> Propert, �f �/ <br /> Owner I// Address _ _ � ity Zih� T`(p Phone#a✓l t Q <br /> C-57 Contractor V Address / ✓Cit Z Z7b Lic Pone 4ft <br /> Consultant/Sub Cntr V.�—� Address �3�Ma�� tr iS7D City�lin F✓��Ci1Cp Lic# Phone ��� � � fv13 <br /> GIS Coordinates:X _?-�,, ?3c( 'y — z I L(z f ,Township 2 S Range ��' Section 7- <br /> WORK TO BE PERFORMED: <br /> NEW WELLIBORING(CPT,GEOPROBE,HYDR PUNCH,HAND-AUGER,OTHER") 16DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# C-, YC — CP ❑OVER-BORE DIAMETER <br /> ❑WELL# IZPRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2 "A ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS /v A TYPE OF CASING:❑STEEL ❑PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL (Q TREMIE TYPE TO BE USED❑AUGERS�HOSE <br /> ❑AIR SPARGE/OZONE j2rPUSH POINT(GP OR CPT)G{'T GROUT SEAL PUMPEDjdYes ❑No (NOTE:MAXIMUMFREE-FALLDEPTH IS 30') <br /> IPMOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS IV& ��^� /�X�`�`^ <br /> ❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <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,and a applicab lifornia Laws. <br /> Signed Title/Company �/,�/ <br /> A,:�,f ` re <br /> Print Name CJ l r 11119/y 4 C_ �—f Date/.D/ o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ` Q <br /> APPLICATION ACCEPTED BY AREA <br /> GROUT INSPECTION BY FINAL INSPECTION B DATE <br /> .wrw <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 /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCR MENT DOC <br /> EHD 29-01 11/5/07 ELL PERMI <br />