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a• u �o SAN JOAQUIN COUNTY <br /> 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> < SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone: (209)468-3449 Fax: (209)468-3433 Web:www.s*- worg/ehid UNIT IV <br /> �/FOR <br /> WELL PERMIT APPLICATION <br /> NON-REFUNDABLE 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 a d the Standards of San Joaquin County Environmental Health Department. <br /> Well Location 0,,,-,I H/6Nwar� wE��Y�O. 6RI44LI Assessor's <br /> I ODS v'1 Cross Street City s Zip 4s385 Parcel#255-1801-Oa <br /> Property �jrTY <br /> Owner WESTERNFA2M rgQV10E Addressbe>EC(MVE DRIVE city COL045VILLE zipb225+ Phone#618.7 1.7324' <br /> R$I �DRILLIN61 Addressy iN• h b64 <br /> C-57 Contractor 2 Z Epi Sr� City WOODLA'MM] Zip°1�77(O Lic#I�A�" ? Phone 2�. <br /> Consultant/SubCntr SAIC, Address3boo WAir,4Vr-, %iT62j0city_T",4MI✓NR7 Lic# -- Phoneglb-9_71•3?95 <br /> GIS Coordinates:X Y Township 3 Sovey Range G 1545r Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ESTRUCTION(CHOOSE TYPE BELOW) <br /> El SOIL BORING# OVER-BORE DIAMETER /Olt <br /> ❑WELL# ❑PRESSURE GROUT <br /> ❑*OTHER GROUT SPECIFICATIONS N$4T CEMEn/7- <br /> l:S> <br /> COMMENTS: w DEer(1Zo `( S G-I 20yUavvlkTE Wi�LL(HW <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ElHOLLOW STEM DIA.OF BOREHOLE 6-0// El MULTIPLE CASINGS[IMULTI-LEVELWELL CASING DIA: 2 <br /> El <br /> ❑EXTRACTION AIR HAMMER/DRa <br /> HAMMER/DRIVEN CASING THICKNESS EC14 10 TYPE OF CASING:❑STEEL PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL 2I TREMIE TYPE TO BE USED❑AUGERS)<HOSE <br /> ❑AIR SPARGE/OZONE ❑PUSH POINT(GP OR CPT)_ GROUT SEAL PUMPED:❑Yes',No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS NERrCE Il <br /> El OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTO C SING P POSED (if YES list specifications in comment section) <br /> COMMENTS: el <br /> �3S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <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=111i C ifornia Laws. A <br /> Signed Title/Company }�CO3fecT FNS t t?c1NM6r✓17at.S�l EN.rSl"/�/ I C <br /> Print Name LAyJy S' Imo`` Date SIB toe, <br /> DEPARTMENT USE ONLY <br /> � <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Q 7� <br /> WORK PLAN DATED: �v ,0� CV,* L ,1P-j <br /> APPLICATION ACCEPTED BY ✓kb�-'l DATE ISSUEDlI i) AREA C <br /> GROUT INSPECTION BY FINAL INS E TIOONN BY DATE <br /> DESTRUCTION INSPECTION BY , n DATE O <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> d2`TD2 O <br /> 0— <br /> ' 073gty !Vk- SR#nO5_YS6'9 <br /> C-57 WC MAIVER C5ttETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />