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OR fG <br />iP6 ..... <br />G 11 200 <br />.:RONMF NT <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.siciov.orci/ehd <br />WELL PERMIT APPLICATION <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />Applicatio-n.iSber'ebOta-de'to.Bayi 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 />Cross Street PG It+ City Zip '152L: Parcel # 1 V5-0 3 607 <br />Assessor's <br />Well Location - <br />Property_, <br />Owner Address 2- 2.01 kk). v‘esi-z City Zip 62o3 Phone # 6,2g6 <br />c C-57 Contractor 1.-• \ Address f-ZON: City QOO4JA-L -14 Lic # 0233 't Phone • 530.-C.F LS---ZqZLI <br />Consultant/Sub Critr . V Address'tar( 01.cVs ---E.,ecc L. 9.,ei , Si-11.)-0 Citkci.m.:_ki:Lc cke.,..;.f.',..._ Lic # Phone 9ii. - . 'S 206 <br />Range GIS Coordinates: X -3 7, qqt-7 , y --17- 1 . 3z.. Section , Township <br />WORK TO BE PERFORMED: ....„ <br />Fl NEW WELL/BORING (CPT-GEOPROBE,„1-1YDROPUNCH, HAND-AUGER, OTHER.) ! :DESTRUCTION (CHOOSE TYPE BELOW) <br />0 SOIL BORING# 5:1- / 1;-'2, 13-3 p OVER-BORE DIAMETER <br />0 WELL # ( '.:.PRESSURE GROUT <br />0 "OTHER GROUT SPECIFICATIONS <br />COMMENTS <br />Title/Company k \\E Ge_z›mc...-k-;)v <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />1:1 MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE /- 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />El EXTRACTION El AIR HAMMER/DRIVEN CASING THICKNESS nia- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL '10 ' TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br />D AIR SPARGE/OZONE 4.PUSH POINTOOR CPT) GROUT SEAL PUMPED: El Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />,SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nect -I- cv ivi &lir , , , <br />0 OTHER: 0 OTHER: APPROX. BORING DEPTH 1-L• 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: (3v1A4 t4 A Wit k-fAL 75`-- -26 <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 <br />Print Name C._ Date 731 .5' 1 015 <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2 13 <br />WORK PLAN DATED: c.ZI (0 b <br />DEPARTMENT USE ONLY Pt' 2150 <br />-slve,1441 <br /> <br />APPLICATION ACCEPT E'ELaY i/MIL <br /> <br />DATE ISSUED OF AREA <br />GROUT INSPECTIO -C FINAL INSPECTION fkY gi:nitekii143-,^1 DATE F f <br />DESTRUCTION INSPECTION BY DATE <br />COMMENTS/CONDITIONS: eiraihJ (4)14W- ck-C, 3 to-eaS °Wall Iv jer ZS' ,u510 <br />, <br />ACCOUNTING ONLY <br />/ / <br />AID # <br />/ <br />FAC # <br />PE CODES FEE INFO AMT REMITTED CHECK # RECV'D BY DATE PERMIT/SERVICE # INVOICE <br />47'o1 5 l' 61 1'5-0307 -----6-1,1A 1-fe---- 8'bl/a ,sR#00.5 ) 2-) <br />cige 2 Zg . <br />C-57 V WC <br /> <br />-WAIVER NIA C57 LETTER OF AUTHORIZATION TO SIGN PE'. <br /> <br />ENCR2ACHMENT DOC <br />CtC/7--LELftPlit'Zze._ EHD 29-01 11/5/07 (WEB) <br />