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08/17/2005 09:57 FAX 916679216 LRS-SACRAMENTO GO • 002/004 <br /> N San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)469-3433 Web: www.sjgov.org/ehd UNIT IV <br /> ` FO Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> µB$'6-SIOfoGol./RISM4N Qp• Assessors <br /> WELL Location - _Cross Street ScHt.trF RD.City T20 cy Zip Parcel# <br /> T — <br /> PROPERTY <br /> Owner Savic69G>rgv Address , city _.Zip Phone# — <br /> NC. I <br /> C-57 Contractor Tv62GFoSuw.c.FY 4AVE.A9fiNT <br /> FE 5W.Cs Zip4X-7DLic# Phone#-A;(-2--903-DOSS <br /> Consultant I Sub Cnb U/?S COIGN of4 Address 211 Cyt1rAgCWLSDg CityS Lke"-Qnbuc# Phone#916--G711-2-e-0 <br /> 'Q�53 301 1 1oB7g19 l s= <br /> GIS Coordinates:XPI O' (0i0t2f 1 ,Y 200-7-734 ,Township 1'zS Range F-S;- Section{�tY" !;TCTiowl 34 <br /> Pt- 6301953 r Lob[6t(eq ell = SL'cT eo 27 <br /> WORK TO BE PERFORMED: <br /> 04EW WELL!BORING�G PROBE,HYDROPUNCH,HAND-AUGER,OTHER•) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# G- 1 Ft% [I OVER-BORE. DIAMETER <br /> 0 WELL# [I PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLEh?-S a 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: — <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 30'4'60' TREMIE TYPE TO SE USED: JI AUGERS 0 HOSE <br /> 0 AIR SPARGE]OZONE AjIUSH POINT(GP or CPT)GROUT SEAL PUMPED: dyes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS .S=30 } 5 -60' <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH 30- 4 6 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: Z G.oT- $USO L04! V nr 2 WSHW PE,tl--outleJ N 30-4 Lem SG.f <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 �� Title/Company Ur2S Cm 2t�D 2AT/on/ <br /> Print Name —DateA���s>, t2 r 2�4z:' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: OEC -5&& D q <br /> Application Accepted By Date Issued q 110 Area q9 7 <br /> Grout Inspection By Date L Final Inspection By Date <br /> Destruction Inspection By Dat <br /> COMMENTS/CONDITIONS: ND W <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3 901 S4- 'g5' oarg !Sl q / of—I SR# 0043713 <br /> C-57_ WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> HHD 29-02-001 <br /> 6/22/04 <br />