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SAN JOAQUIN COUNTY <br />7±-1NVIRONMENTAL HEALTH DEPARTMENT <br />aCIE;H w it=2, 00 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />JUN 2 5 2008 <br />WELL PERMIT APPLICATION <br />FILE COPY <br /> <br />SITE <br />MITIGATION <br />UNIT IV <br /> <br />ENVIRONMENT H <br />PERMITASERVIC N-KEFUNDABLE 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 />Assessor's • 0345 . CI <br />Well Location243 0 14/ 1,1•44,54/%714-1 Stross Street fo,--t- g 00,,,t 2. / City St4 is0,-N Zip 1-5-203 Parcel # 1/.s"--egli#A-W07 <br />Property er <br />Owner i 0.4- o -r St. c_kt-6,-, Address-22 CuV 14/. 14/454;.,3 fon .-CfCity S-foc-killor) Zip ?Ss-2,03 Phone #°?. ?SI C. a2 (71 6 <br />C-57 Contractor Vi r-oil ex) 2,7 c... Address S-2 92., ea (-4 e cc, S/vot City /9 c-hec, Zip ?V.C.C3 Lic # 7os ?2:7 tPlifOLA/. <br />(C-onsultant3ub Cntr grt.7 4,41 miik C444,4:.4.‘i Ao 1 1 i i C--/ vic_ 46e- City 11.Z. /P14- 6'e `Et # — Phone 7,1.5-. Y37. 70/0 <br />GIS Coordinates: X 6 9 7 'V `MSS; , Y '1, 0 /07 0. /?s_ ,Township /A/ Range 6£ Section <br />WORK TO BE <br />pid NEW WELL1ORIN CPT ROIHYDROPUNCH, HAND-AUGER, OTHER') El DESTRUCTION (CHOOSE TYPE BELOW) <br />SOIL BORING# 0 OVER-BORE DIAMETER <br />7/1) WELL # -r-(0 PRESSURE GROUT <br />*OTHER 2,40 GROUT SPECIFICATIONS <br />Ate4;o1;./ Al Att.( aaedeLt.e 04sid := 25-26 Id- ali 44% COMMENTS: <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />0 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 2/11 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL -.a TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br />0 AIR SPARGE/OZONE tie PUSH POINT (GP OR CPT)‘ P GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />Ca'SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS _k,j1A---"- <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH 2. 0 " 0 BOLTED TRAFFIC BOX OR 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br />COMMENTS: <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 fornia Laws. <br />Signed <br />Print Nam <br />Title/Company 5.Gs7fi, Eli is, gr-o <br /> Date <br />SITE MAP MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br /> 6 <br />APPLICATION ACCEPTED BY <br />GROUT INSPECTION BY <br />DESTRUCTION INSPECTION BY <br />COMMENTS/CONDITIONS: <br />(72-/ 3 Os Izt nr_S <br />DEPARTMENT U;Nk.Y A <br />DATE ISSUED — zqok AREA a-eV <br />FINAL INSPECTION BY <br />DATE <br />DATE <br />ACCOUNTING ONLY: AID # FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />-MI S-e 4F51- bri0.3 SR# f0f540 7-- <br />C-57 V WC <br /> <br />-WAIVER <br /> <br />C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> <br />EHD 29-01 11/5107 WELL PERMIT APP