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• FILA COPY <br /> oPq in,, San Joaquin County o <br /> Environmental Health Department RECE V a SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/eh9UL — 6 2005 UNIT IV <br /> LK•• �P <br /> Well Permit Application ENpV�IAONMMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE d`RM[T/i ER\ACES <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 NMW-t <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. 191-150-04 <br /> Mo.n:lo, Rd. Assessors 1°11- 2.40-13 NNtW-� <br /> WELL Location Freta Bre Rd, Cross Street MonAhey Rd.City Lo-Vn"e Zip 953710 Parcel# 1g -140-15 NMw-3 <br /> 19 I- 7.40- 17 NntW-W <br /> PROPERTY 1-77.$7 5, Man;'hey Rd 191-170- It NMw-f <br /> Owner'riCt4 PcoeerAes Address p-0- (Sox 310 City L4 Phoned;Pg)lax-lsGv <br /> C-57 Contractod�pet4 Pq loralionAddress 3365 W[I3wafn Dr. City S+ec Zip iSo Lic#5111(e Phone#U09� 4445-8717. <br /> Consultant/Sub Cntr E�1r se Tnt. Address 7.880 Wfr%ty I31Vd. City cn,c Lic# Phone#x q,�L& S-O(s10 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> SOIL BORING# n OVER-BORE. DIAMETER <br /> WELL# $ n PRESSURE GROUT <br /> D'Other GROUT SPECIFICATIONS <br /> COMMENTS: Ce,n S•F vt.A- a o1; 65') ^014 cd ro if 11.Julr! frons 46vi 1):3 wells <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS u <br /> MONITORING ,HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: . <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS 0-7) TYPE OF CASING: n STEEL 4PVC D OTHER: <br /> n VAPOR D MUD ROTARY DEPTH OF GROUT SEAL 1L TREMIE TYPE TO BE USED: D AUGERS n HOSE <br /> n AIR SPARGE/OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes gNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 31 <br /> n SOIL BORING n HAND AUGERGROUT SPECIFICATIONS Na k Ccf�erx+ <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH IAO ' n BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Wit 1% CWC -1 t IoG �on5 a5 warK P10... CAe0cnded b4 RWQC3 <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, Ru a and egulations,and all applicable California State Laws. <br /> Signed Title/Company Sru_r� fGe IOjk S4 EN6E.B SAC <br /> Print Name Cr ">C.ra Date 6�zu 10S <br /> DEPARTMENT USE ONLY ��j� — <br /> SITE MAP IN UNIT IV FILE, ADDRESS: raDmitL4l1ii? 5 Z✓ <br /> WORK PLAN DATED: ^ <br /> 7 /. _. _ Date Issued 7 -CO �5 Area 9f s <br /> Application Accepted By 4 [•�"�"'� <br /> Date <br /> Grout Inspection By 01 <br /> Date Final Inspection By Date_ <br /> Final <br /> Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK p RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S1 I33- G>,-A 7- S 0 y�g9 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc—Qe <br /> EHD 29-02-001 <br /> 622/04 <br />