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,o 0o SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> y { <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax: (209)468-3433 Web:www.s' o �� T IV <br /> WELL PERMIT APPLICATION OCT <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 2 12009 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This ap with San <br /> Joaqui County Development Title, hapter 9-1 15.3 and the Standards of San Joaquin County Environmental He alt 0'1�1111149JHnce <br /> ERVC <br /> Well Location n +ttt(c, J1• Cross Street �U' Lt7 City Zip Parcel# <br /> Property F/ Address 311 S N ,W I p <br /> Owner U ��ll ,t�(,� S�� I3� City Wu�►�u�"/C��.c.��zi 5��4� Phone#9Z�5}`� '�oz7z <br /> C-57Contractor WucW 1N(+V Address Sso �,j�/ P4 City �►(�V13'Trk A <br /> #i/00 hone +0- "�4 5'0 <br /> Consultant/SubCntr Iii 1, Address-Z--T; �u��l �� City 1n�QlKJ����iI1� #6�Zsy Phone qZs2��j s(�0 <br /> GIS Coordinates:X v -[ ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') —00ESTRUCTION(CHOOSE TYPE BELOW] <br /> F1 SOIL BORING# OVER-BORE DIAMETER <br /> ❑WELL# i, ,PRESSURE GROUT <br /> #OTHER + I.n // J �C' GROUT SPECIFIC[ATI�ONS I <br /> COMMENTS: [ M GL To 49- l C b� 1 -[Gi'r�l�l ) li �(q'Vui_ rt` QB SQ V�lR,il.T- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MONITORING AHOLLOW STEM DIA.OF BOREHOLE �_ ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: <br /> ❑EXTRACTION ❑AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL kPVC ❑ OTHER <br /> ❑VAPOR ❑l MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USEDkAUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE lf�PUSH POINT(GP OR CPT) GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH <br /> IS 30) <br /> ❑SOIL BORING1. Ag ✓✓✓❑HAND AUGER GROUT SPECIFICATIONS jCCIPJ--�. N��� lfCd.� W" X4-( <br /> ,OTHER: G OTHER: APPROX.BORING DEPTH 7 ❑BOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> ` C44NDUCT R CASING PR OSED (if YES,list spe0ications in comment section) <br /> COMMENTS: t�1'�� y k eLW, ✓L)G I r <br /> NOT. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certif that I have ep d this plication and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations nd all a c �Califor Laws. I l <br /> Signed Title/Company S f, ?�61•RC� ��tiLO+; 1 4('s� <br /> Print Name <br /> S C.o` �lt.y Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 0AA 1 IV^ I; 44,Cc,l 1( 1%4A. G 11 G P n D V <br /> WORK PLAN DATED: O (L O 1 11616 WWI I/ <br /> APPLICATION ACCEPTED BY DATEISSUED ty lZ�l00 AREA '5G <br /> GROUT INSPECTION BY n�c'Gv� I I I f'Ljocl FINAL INSPECTION BY��4�YtAit�t!��\ DATE <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 /> Zjo2 (+o.,/V 0 10�3?� coda o R#S$6SS <br /> c-57 WC{- -WAIVER C57 LETTER OF AUTHORI ATION TO SIGN PERMIT ENCROACHMENT DOC <br /> END 29-01 11/5/07(WEB) WELL PERMIT APP <br />