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o? • U.1 •San Joaquin County <br /> Environmental Health Departmo SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sj9ov`-ckRd2 2 2006 UNIT IV <br /> �gcrFo$d`P Well Permit Application ENpVIIRpONWNf HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUEY 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 Joaquin County Environmental Health Department. 15( —3Z O 19 9- <br /> �QOQ 5 • /�-i4Nn-p. 'S�'ri'KSON SCi r $�,qP�L'tt'N`" 9'5_06 Assessors/5 p <br /> WELL Location • Cross Street City Zip Parcel# i-3160 <br /> PROPERTY r ,/ - ,/ �QOO • /�41d7i� $II• �ItgG�Lfp. ��6 O C�f�o 4'/000 <br /> Owner J/l n /�y4V0 ,M&IAddress �1 S City ''__�Zip LPhone# —70-1 t ' <br /> C-57 Contractor A6Z Address ZZO N - Fcl 5{' Cit IIl! d Zip 774j 023_Phone�S3d 6Gg'ZA'/Ly <br /> Consultant/Sub Cntr_�)4&YKQJf'/'f`F Address 10 670 6t1lw{! Afe-Ay A d• Lic# NSA Phone 9/6 G 36 '3?oa <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> U NEW WELL/BORINr (rPT rrnoROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a DESTRUCTION (choose type below) <br /> SOILBORING#. 3 _ DOVER-BORE. DIAMETER <br /> D WELL# D PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS:_ 3 k'rh!ss W4/( 6'e- 0.40& e4d Ori Propet-4-1 D '� _�}D �Tf• <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING a HOLLOW STEM DIA,OF BOREHOLE Z is D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS _TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEALD_4U / TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes ® (NOTE:��MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORIN D HAND A GROUT SPECIFICATIONS 'tI% Ayq- 'N& 7tnn'w <br /> a OTHER: OTHER ✓c4 APPROX.BORING DEPTH ?.40 r a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CC__ CONDO TOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Imo/ /•�'r•O /)t Ly <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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed z /�' �vr Title/Company �Cr w��� 1 y/ f/C <br /> Print Name 0 PW /N al w Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 75/2--7/0f, <br /> �1 <br /> Application Accepted B Date Issued )/2'? 0f, Area_qR._ <br /> Grout Inspection By Date3t2,9 I D&2 Final Inspection By Date Y <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: ! <br /> ACCOUNTING ONLY: AID# U FAC# <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> O p3 D sR# 0 (, u(v <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />