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oQ'uf 'an Joaquin County <br /> Envird*mental Health Department SITE <br /> �'. 304 East Weber Avenue, 3rd Floor, Stockton, CA 9 <br /> J <br /> ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov. � � <br /> UNIT IV <br /> Well Permit Application MAR 1 6 2006 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I kNMENT . EAS <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describ�pTglais�y� de in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environ e l nt. <br /> '/�� --Assessors 7 <br /> WELL Location 1��{ J�a �^"^7 Cross Street City `'i " Zip��'�S Parcel# �� ) <br /> PROP Tl( ��1 Address 100 '&D Phone#2% T 6J —�-7 <br /> Owner ' !� �1p�2�� f�� W City� 4/1�,�]Zgip /� ,r� <br /> C-57 Contractor llX /�Q Address9bhec��Cii yp) 71 "phone#g�6 JrD,'3��W�4/ <br /> Consultant/Sub Cntr 46 r- Address J� SV�1' �O� City, c# Phone# `�&�1 6i�{o <br /> GIs Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> EW WELL/ BORING (CPT,GEOPROSE, HYDROPUNCH, HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER- <br /> XWELL# D PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MI <br /> ONITORING OLLOW STEM DIA. OF BOREHOLE '-C�MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA. <br /> 2_ <br /> /0\EXTRACTION rAIR HAMMER/DRIVEN CASING THICKNESS — TYPE OF CASING: 0 STEEL Z PVC D OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL � TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED:rg'S'es D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX. BORING DEPTH 1pS'leD QOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> S <br /> p K� �UCTLR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: IV I V3 (n <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 Qrdin nces, Rules and Regulations, and all applicable California Stateaws. <br /> f ,/ /r � <br /> Signed x w r► )'1. �� Title/Company '6 © C <br /> Print Name �/l/� / '^ 1 lr Date 311,614 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1©ll 0 rt9 <br /> WORK PLAN DATED: <br /> Application Accepted By Date IssuedT7� Area <br /> Grout Inspection By 44, L<-Ab I k Date 3 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <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 />