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02/17/2006 14 10 2094683433 EHD PAGE 02 <br /> Qtj I San Joaquin County <br /> s Environmental Health Department Z4p6 <br /> • a r { 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIIrIry <br /> (209)468-3449 Fax (209)4683433 Web www sjgov org/ehd uNIT t,9. 41rH <br /> P Well Permit Application <br /> HON-REFUNDABLE PERMIT EXPIRES I YEARFROM DATE tSSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andfor Install the work described This appllcatton 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 2:�kO S k-0--5-4- Cross Street city. L _Z)p—Parcel#_Qr►.'1- 1L."t.)-c <br /> PROPERTY <br /> ownerC.�r�We _ G r.�c Addre;sCaocl� L',rLnste _city,so-c% Zlp`1`1�'l 3Phone# 2.57 $LlZ-IS 1, <br /> '^tea. <br /> C 57 Contractor '-M-11 -Nt-r- city a 2ip`1��i`te{Ic# 1 St hone$ t �n3$ -ii�rt <br /> C.. Cep �, S'1`Z4$ <br /> Consultant t 5tia CnSeer..;- maz, <br /> tr r -I`adlress 3,,to t A t-kJ UACrty i ..;�:,4 uc.#_ Phonef(,1%I ) <br /> GIS Coordinates x Y Township Range Section <br /> WORK TO BE PERFORMED i <br /> rEW WELL 1 BORING (CPT GEOPROBE HYDROPUNCH,HAND AUGER,OTHER') a DESTRUCTION (choose typo beioM <br /> jI SOIL BORING a jI OVER-SORE DIAMETER <br /> ,'K1NELL# 11 PRSSSURE GROUT <br /> A 10ther GROUT SPECIFICATIONS <br /> GOMMENTS <br /> TYPE OF WELL INSTALLATIDH TYPE CONSTRUCTION SPECIFICATION$. <br /> KMONITORING HOLLOW STEM DIA OF BOREHOLE fi�_ Q MULTIPLE CASINGS p MULTI-LEVEL WELL CASIyG DIA <br /> a EXTRACTION jj AIR HAMMERIDRIVEN CASING THICKNESS,-k�i- TYPE OF CASING 0 STEEL XPVC a DINER � <br /> D VAPOR Q MUD ROTARY DEPTH Or GROUT SEAL TREMti_TYPE TO Bt=USED B�AUGERS 0 HOSE <br /> a AIR SPARGE!OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED 1)Yes a No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> . a SOIL BORING n HAND AUGE=R GROUT SPECIFICATIONS_PcSr� <br /> a OTHER XOTHER Son,t� APPROX BORING DEPTH V BOLTED TRAFFFG BOX or tl STOVE PIPE= <br /> CONDUCTOR CASING PROPOSED 7.q_-\a 11 r (if YES list spetriicatinns In commant section) <br /> COMMENTS 74" rna,,e�,..b,-:,.4��,rW_r CL. 3vL, e.,w-S0. r11,w� l0.�rtirr•"STs. , ��,$rnw-Io <br /> riTO N i vc, <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGR1 EMSNT 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 wrth San Joaquin <br /> County Ordinances,Rules and Regulations, and all applicable California State Laws <br /> Signed x `r1r1 TitldCompany k Sc',�rr4�,,k-� .tui �r,'far t�r� ,. <br /> PrintNamc 'rtc �a _ —Dale �5 Ota i <br /> DEPARTMENT USE ONLY ' <br /> SITE <br /> PLAN DATED' � z,-+--]C,5�-- d5-SITE MAP 1N UNIT IV FILE ADDRESS._"d <br /> ARPltcatron Accepted BY (k-.y Date issued_ '2- to� Area` <br /> Grout Inspection By - Date Final Inspeclion By i- <br /> Destructlon Inspection By Date <br /> Cotuit�t�HTs r caNamaNs _-_ _ _ -- <br /> ACCcx1NTtNG ONLY Ala# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY RATE PERMIT/$BRVICt REgUEST�r INVOICE <br /> 3Sv 1 4 .no {�`(23o7i -� j SR# 56 <br /> C-57 WC„_ -WAIVek— C-57 Letter of AuthoriZof ion 7o sign permit_l;hcroachment doc_ <br /> . EHD 29 02 Ott t <br /> t�zzroa <br />