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Signed <br />Print Name a_ 0' (Oe'Lk <br />FILE COPY <br />SITE <br />MITIGATION <br />UNIT IV <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br /> ephone: (209) 468-3449 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br /> <br />AUG 1 1 2008 WELL PERMIT APPLICATION <br />ENVIRONMENT HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />AppricaticRERAWSIAViCES, 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 />61 04ra <br />2201'J, Eas-4 k. - <br />Well Location 2.130.A), WaS11% nc41)}1 S4-. Cross Street <br />Propeqy <br />Owner VD( S1/4-ock <br />C-57 Contractor Address <br />Dc_v_ <br />Address 4201 u). Oastni tv3i-ovk SA- City v•-‘ <br />City QCOCIJAY14 <br />CityDr zip 4 /52o3 <br />Zip £L0 , Phone #,20-q(o -10.2416 <br />Lic # 0233 tt Phone <br />Assessor's <br />Parcel # I42O 3(40? <br />Consultant/Sub Cntr AMC-4076),A,DA-r;g Address 106-1D(-Ice2ocic S41bo Cit C0cckOJc Lic # <br />GIS Coordinates: X -3 7. qq , Y 17- I .3Z.. , Township <br />Phone 91(a • la Y.,. ZOO <br />Range Section <br />WORK TO BE PERFORMED: <br />3 A NEW WELL/BORING (CPTc-GEOPROBE YDROPUNCH, HAND-AUGER OTHER*) <br />SOILBORING# 511 Pii2, g -3 <br />['WELL # <br />D *OTHER <br />COMMENTS: <br />.1 'DESTRUCTION (CHOOSE TYPE BELOW) <br />fl OVER-BORE DIAMETER <br />I .:PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE Z 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS rqa-- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 2-0 TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br />0 AIR SPARGE/OZONE kPUSH POINT R CPT) GROUT SEAL PUMPED: 0 Yes A-No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />X.SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Nett -I- 2 M &')7Y <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 all applicable California Laws. <br />Title/Company l'AEC- Ge_Dolu1/4--;)0 <br />Date -?3,1'€5 1 015 <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: c8 1(010 <br />DEPARTMENT USE ONLY f2 ,2150 <br />2 1 -30 LA) ee”- tAhL4)i --foN1 <br /> <br />APPLICATION ACCEPT DATE ISSUED q/q/OF <br /> <br />AREA <br /> <br />GROUT INSPECTION BY FINAL INSPECTION BY DATE <br />DESTRUCTION INSPECTION BY <br />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 />[-47.01 /4' 6/ 15-030 7 -,-th-InTte-__ E3h i 1 a ..SR# OD -',5 )24 <br />C-57 V WC I -WAIVER i.ilA C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ( ENCR,9AtcHMENT DOC <br />(... END 29-01 11/5/07 (WEB) 11.".41 LfgearA• t2t' A0' A