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*ro <br /> fkan Joaquin County nn • <br /> Environmental Health Departmnno EC � �"l SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.JRVdl 7 2006 UNIT IV <br /> Well Permit Application ENVIRONMENT HEkPi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISEkWIT/SERVICES <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 /> Assessors <br /> WELL Location 03S E AST AL-?I rJE WICross Street[✓.�[ L^- " City S'Ta-V-TOIV Zip q5 Parcel# 11 7 0$00 cl <br /> 'PROPERTY <br /> .Owner•i'rlomAS T tWM1A SuiNEIIbEMdress/MY E.Af-PI.yE PNC— City Sl C-V'MUN Zip95209_Phone# ZOq- L(66-196S <br /> C-57 Contractor ENPfoBE Address go,30x 6og3 city LLe Zip 166 Lia#77707Phone#S-30- S19-2o19 <br /> Consultant/Sub Cnlr 7_e�^A co" Address71fol Gqw Lea k0. CityF-OSe_u.1G Lic# N A Phone# %/b-7 8 ti-LZS 3 <br /> GIS Coordinates:X /0326166.SS V 214'73�10•N 6� •Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> MOIL BORING# Z- 0 OVER-BORE. DIAMETER <br /> p WELL# 0 PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: SOtL Sq,M?`t NG Or--t T — N C, wr-t.� t rJStAL. ^-nonl <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z` 0 MULTIPLE CASINGS p 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 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> p AIR SPARGE/OZONE QPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> .SOIL BORING aHAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH ?_C7 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> L CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS:-.0-n a;� PDrynY�Dv-1 „no�� <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 a plication and that the work will be done in accordance with San Joaquin <br /> County Ordi ces ul soman egul ns, and all applicable California State Laws. L <br /> Signed x I I Title/Company Ny I W+�1MG�W'1 Ptt Eo L-o G,t S-S / l�.ttAc.o-N <br /> Print Name M(C.1446L. SC-IN MgcE-}EJL Date,/I- [6-O 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FIL ,A4DRESS: i9 3V erg <br /> WORK PLAN DATED: II�I(„I h LD <br /> Application Accepted By1 Date Issued 1117 7/06 Area 9� <br /> Grout Inspection BDate 1 Z y 0 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CON DITIONS: 5;�A C li'Pi" kliA t, 1. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ,19.01 T7 .. yq 01/ 6265 141-. 1//27/PL SR# 04� l ? <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHIJ 29-02-001 <br /> 6/22/04 <br />