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e �o 4kan Joaquin County o <br /> Environmental Health Departm9t6CDPDOD SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.olt"d2 2 2006 UNIT IV <br /> L A Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE MU T/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 p <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San <br /> SanJoaquin County Environmental Health Department. <br /> /S) — <br /> O� 40• Tef444S0K SJr SfVSZOe Assessors <br /> WELL Location 1600 5TwOr Cross Street City Zip Parcel# <br /> isi-SW Z <br /> PROPERT� r 1� w t. VMA4 , q•$y06 <br /> Owner //W Address 400 S' Aom City Zip Phone#('?0 94B•'1000 <br /> C-57 Contractor JaS Z AddressZ`X10 N • �Bf St• Cit"Od LodZi -p 577 Boz33`�hone 4S, d 6 Gg'Z 4/Ly <br /> Consultant/Sub Cntr04ff AW0'h!Y Address id 670W4114 AIIIglill"etilroI A•C• Llc# NIA Phone 9/6 636 .31oa <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW VI(ELL/BORING MPT r-rnogOBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> fdSOIL BORING#. 3 - a OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> 0`Other GROUT SPECIFICATIONS_ <br /> COMMENTS:_ 3 b072L'%sS fes+)!( 6•b QdyOwcea <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE Z e 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&—=40•'4V f TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br /> 0 AIR ONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes® (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORI 0HANDA GROUT SPECIFICATIONS N% Avg- is - fjnuA <br /> 0 OTHER: OTHER •✓CG APPROX.BORING DEPTH Z O , 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CC-- CONDOLCTTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: /��� 407''L107 Ma <br /> 01 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, <br /> Rules and Regulations, and all applicable California State Laws. <br /> Signed x •� /\ � �� ,r t Title/Company t>C;w � //7� ,(f f JC <br /> Print Name �r'(.p /,1LNOZ rA- Date 312/106 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted / Date Issued /�'� �� Area 99Q <br /> Grout Inspection By Date 3(Z=`t 0(2 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: Jl ems• t <br /> ACCOUNTING ONLY: AID# U FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 02 All L41 b-1 <br /> 3 D SR# G?D(o <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22104 <br />