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09/08/2006 07:44 FAX 9166792900 ITRS-SACRAMENTO-CO Z002/004 <br /> 0 0 <br /> oSan Joaquin County <br /> Dy <br /> Environmental Health Department SITE <br /> a 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> ' 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 9-11151I.3 and the Standards of San Joaquin•County Environmental Health Department. <br /> WELL Locatlon 2.S),U.D U�2/ �/✓ /J,, SY�K�ITm 7 Assessors <br /> N�Cross Street C;MIZVA�AIJ Ci Zip�6 Parcel# Z&2_07'90 Z <br /> PROPERTY <br /> Owner_Z✓5 Caa,.StlV.atiFr.:l- Address 7,ThOZ>c'Nd r_W0ej ority ` Zip 5�3 37L2.�-233 <br /> Phone# e <br /> C-67 Contractor<Sf��-J'4-4 N'6 Address 7SA//0K,9 JI C`itY±AGE_r-E�tZip S33Lic#_(0` Ph 3/3_"'I <br /> Consultant/Sub CntrLIA.7 fLr[.P. Address'ZR7D=*Allc ityS ' Lic# -- Phone#S/6 L.77' O <br /> GIS Coordinates:X DT A17�Ai&f ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 8 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> I��ILBORING 9 fjJfA1 O>� GGr /(bcfiJ r '-Awa aOVER-BORE. DIAMETER <br /> Q PRESSURE GROUT <br /> 0*Other GROUT SPECIFICATIONS <br /> COMMENTS: _ � MsvO7®f�- [-ppy}�y�/ ,a p <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> u MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA' <br /> u EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: u STEEL 0 PVC a OTHER: <br /> 9 VAPOR u MUD ROTARY �1DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: D AUGERS a HOSE <br /> D AIR SPARGE/OZONE AOUSH POINT(GP oPr;ryrGROUT SEAL PUMPED: O Yes ONO (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING u HAND AUGER CV/ GROUT SPECIFICATIONS S <br /> U OTHER:_O OTHER APPROX.BORING DEPTH 2.0>-&Z>S SR BOLTED T FFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: ✓ .[_S r-CW1iA9,/Wb j e5 .Sji'q.V -}VP7- /Q 7-,7 <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 x �G /6 '�L Title/Company // S /ys �cGfy'LQ'1JpJ�� <br /> Print Name - ? Ni+n/ Dale / — ZfDCJ�e <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: nr <br /> Application Accepted By Date Issued 'Vit Area 99' <br /> Grout Inspection By Date � Z Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: V✓L.lo S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> q111 D SR# p0`-('9 t <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> ERD 29-02.001 <br /> 6r12/04 <br />