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FILE COPY <br /> p�u rk ON 1 6 2,0San J08 �o .aquinCounty" ,­ <br /> � . <br /> : <br /> ` NMENT HEALUvironmental Health Department SITE <br /> IT/SERVtCE90 East Main Street, Stockton, CA 95202-3029 , MITIGATION <br /> (209)468-3449 Fax: (209)468-3433,W6b: www.sjgov.org/ehd m UNIT IV <br /> Well Permit Appl-ication ; <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 0(f/ <br /> k <br /> Application is here y made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in m fiance with San 3 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the'Standards of San Joaquin County Environmental Health Department. <br /> Assessors _ <br /> WELL Location_1 t} cS pW pp d• Cross Street A Mon City S DCk}9f� -Zip�CJ715 Parcel# 01 <br /> PROPERTY[/ /Gtr �// �AWM <br /> Owner q��+.ddre-S0 - City Zip Phone# 7 �r. j <br /> T1 �4nc�n o <br /> C-57 Contractor� [ � yJn�11r1Q Address3r0�j?_ DvxcC/bore City ern9cJra- ZIp_J!ZLic# jldf'hone# <br /> Consultant/Sub Cntru1antSAddrass� —� Suitt lti0 City Ays�in Li c# " PhorieiFJ�/'- ��; <br /> GfS Coordinates:X 3 ���8 S ,Y-1Z i .-Z4 S'Q'( r/,Township i. Range Section Jf <br /> WORK TO BE PERFORMED: s <br /> NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTIONyp <br /> a SOIL BORING# {choose type below) <br /> 13OVER-BORE.. DIAMETER <br /> WELL#_V3 -tSr rn10-ISp 0 PRESSURE GROU"f <br /> 0'Other r r <br /> Ory GROU7 SPECIFICATIONS a I <br /> COMMENTS: <br /> f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> I MONITORING N HOLLOW STEM DIA.OF BOREHOLE g� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 02. <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN} CASING THICKNESS ..40 TYPE=OF CASING: 0 STEEL I PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL {a •PREMIE TYPE TO BE USED: J AUGERS a HOSE <br /> p AIR SPARGE!OZONE I)PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes I No (!VOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER: Ii OTHER APPROX.BORING DEPTHO'`r r'SS BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED '(if'YES,list specifications in comment section) <br /> COMMENTS: - <br /> i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE'REQUIRED FOR INSPECTIONS. <br /> I hereby pertify that I have prepared this application and that the work will be done in accordance with San,Joaquin � <br /> County�Ordi noes, Rules and Re lations,and all applicable California State Laws. <br /> Signed x TltfelCompany f 7Rf? O j 7 <br /> Print Name er!G /I/U8 �K/�r <br /> Dale <br /> DEPARTMENT USE ONLY <br /> 46 <br /> SITE MAP 1N UNIT IV FILE,ADDRESS: odd i° 3s` Z APyt <br /> i <br /> WORK PLAN DATED; 10—16 __V r <br /> // <br /> Application Accepted By Date Issued I6— 'Q P <br /> Area <br /> Grout Inspection By RDate. Final inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONO-WAIVER-- <br /> ID# FAC# <br /> PE CODES FEMOUNT REMITTED CHECK#,.,,,, : REC'DBY DATE, P.ERMITISERVICE REQUEST# INVOKE <br /> OF <br /> C-5 WCC-557 Letter of Authorization_tosign permit„-Eaalme rr'f'men#doc_ �/ <br /> EI D 29-02-001 WEB tty"'"�i =.-: I✓/ <br /> 9111/2007 R OA— _Zt <br />