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` <br /> * 90 <br /> SAN JOAQUIN COUNTY <br /> ENANMENTAL HEALTH DEPARTMO SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sigov.org/ehd UNIT IV <br /> AUG 2 5 2008 WELL PERMIT APPLICATION <br /> ENpVIIRpON�PT.,1/EIN�T /HEEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> App fc'etltlW- hateDy'rQAo 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 /> Assessor's <br /> Well Location 3729 TOC.Y SSP. Cross Street LA RCR a. City w4cy Zip _ Parcel#. ,LI a-1 71 C >0 <br /> Property <br /> Owner SHI6" 0It-PR0DvcS US Address 201455-wtLHiN&'[bNAVd City CAk'soN Zip 90810 Phone# 9K-84P-94 <br /> C-57Contractor QACEG(x DRILNNCn Address "so twwE 2D. City Mt}R.i'INea Lic# 44 % Phone `t?S-913-3241 <br /> Consultant/Sub Cntr VIZ& rnc.P. Address 13&3 Broftu+RY sm.,sco City OAwLAND Lic# Phone Stn-174-3242, <br /> GIS Coordinates:X 121'U'4.5S V W ,Y 37'14S'411r.34 0 N Township TRACY Range Section <br /> WORK TO BE PERFOR <br /> NEW WELLIBORING G OPROB YDROPUNC HAND-AUG ,OTHER•) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> SOIL BORING# ❑OVER-BORE DIAMETER <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 3' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:0 STEEL 0 PVC 0 OTHER <br /> ❑VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> ❑AIR SPARGE/OZONE %10 PUSH POINT(GP OR CPT)!�'—? GROUT SEAL PUMPED:❑Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS 1.11 <br /> I <br /> [:]OTHER: _ 0 OTHER: APPROX.BORING DEPTH 20 -Pt: ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSE (if YES•list specifkaticns 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 h e prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations,and 1 licable California Laws. <br /> Signed Title/Company <br /> Print Name CJkCob VIS Date Z �� <br /> ..// <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 37/25' <br /> WORK PLAN DATED: WL.1t- L ('1 ?,00 O nn <br /> APPLICATION ACCEPTED �� , 1L / DATE ISSU D AREA _I 1 <br /> GROUT INSPECTION BY 41 <<MR"�1 FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: SSA a t?�a LbP S <br /> �• - C <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> 39.01 8q 89— a k I sR sS a 8t- <br /> C-57 WC -WAIVER C57 LETTER O AUTHO IZATION TO SIGN ER IT ENCROACHMENT DOC <br /> EHD 29-01 1115107(WEB) WELL PERMIT APP <br />