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. c.G <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> -C[,U'� 600 East Main Street, Stockton, CA 95202-3029 SITE <br /> hone: (209)468-3449 Fax: (209)468-3433 Web:www.sigov.or /ehd <br /> a >' g UNIT IV <br /> APR 1 4 2008 WELL PERMIT APPLICATION <br /> ENVIRONPOEW HECALTRON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is�liel��lti>`ald�WJtlaquin 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 /> `rf <br /> Assessor' q <br /> Well Location—A-422 SIT <br /> N V St Cross Street C(,NXor�;q S-tM� City S'�OCk-M Zip �(�L Parcel# 13 t�zs�-DS <br /> Property LL�J ,�11 /I __ <br /> Owner A,-Y� .! ( D►tit�P✓ Address ZOO k City 5•�. Zip [Q Phone KfS)S(>`j-$O-53 <br /> -- <br /> C-57 Contractor Address 3632 O.'heC 6-rtle City V2AA Ino COr?u,p;�Zip `49-74Z Lic# 717S-) Phone <br /> Consultant/Sub Cntr ACL,.A;S Address -,i,50 6. GIpnn Dr ,W- City 13�, Lic# _Phone � � K1- <br /> 2479 <br /> GIS Coordinates: X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> ❑SOIL BORING# ❑OVER-BORE DIAMETER <br /> WELL# S16•-1 ❑PRESSURE GROUT <br /> ❑`OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE '7 ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS • '40 TYPE OF CASING:E3 STEEL),PVC ❑ OTHER <br /> [I VAPOR El MUD ROTARY DEPTH OF GROUT SEAL I SO' TREMIE TYPE TO BE USED❑AUGERS X Tr t mwi-c <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:Jeyes ❑No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 5'0�o JC-—e-C-7C,rrt Gr,,+ ehtn'hrr•e <br /> ❑OTHER. XTHER C APPROX.BORING DEPTH 15-0 ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> C,ONDUCTOy,CA_SI-NG PROPOSED U YES,list spemica6 ns in comment sectio <br /> COMMENTS: - 1`$� a7YGL4 �.��,�� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT ORENCROACHMENT EPIT <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 all applicable California Laws. <br /> Signed „4t2— _Title/Company <br /> Print Name M-4+ Kret16,c I Date C <br /> DEPARTMENT USE ONLY Cop IN <br /> SITE MAP IN UNIT IV FILE,ADDRESS: a y Z S ln, v �•�. 1 S�r��L <br /> WORK PLAN DATED: it I lk I o <br /> APPLICATION ACCEPTED BY DATE ISSUED Ll > C AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE q4om- <br /> DESTRUCTION <br /> 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 /> -ggg.vo 03,103S (,� y is o� SR# 539 <br /> C-57 WC WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 <br /> WELL PERMIT APP <br />