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FILE COPT <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> � 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> • /FORN� Well Permit Application 2006 AUG 14 PM 12: 22 <br /> NON-REFUNDABLE PERMIT EXPIRES 1YEAR FROM DgA14SUFRUI)Ijv COUNTY <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wor made in compliance with San <br /> �� � -Rout <br /> Joaquin County Development Tit18,Chapter 9-1115.3 and the Standards of ggan Joaquin County t a t. <br /> (:&Vn4y 1lgh?-�F-M+q`� �Irtwoo'b Ave, Assessors <br /> WELL Location Ya45 bi(FaA III& Cross Street F/AesK/r'W A.e City •Sw 1[to i Zip Parcel# <br /> �>LI" 11 <br /> PROPERTY ta5-! E/MwoyJ 1'[',Q4 3940 <br /> Owner S. S PvIS�I Address /a/40 146 <br /> Omer City SIot,ICTry� Zip ysQ9 Pho�s4 ya <br /> `z.o� Yw <br /> / `15 oi N wf h AA CityMAr T10V2. zlp94SY3 ucu P one# t S III SS o D <br /> C-57 Contractor G � Address D <br /> Consultant/Sub Cnlrddress837 5ijAW Rj city .57r9kKmnLic# p72y Phone ta4 yIs 2—/ 0' <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING PT GEOPROBE, HYDROPlYNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type below) <br /> *OIL BORING# CP 1`l I CPT-ij &1''�v DOVER-BORE. DIAMETER <br /> WELL# D PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: S F i— W G f K Pilau DArto d prj 0 Zs� L <br /> i <br /> TYPE OF WELL INSTALLATION TYPECONSTRUCTION SPECIFICATIONS N/ <br /> D MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 1'4q' 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: A <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS N IA TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: !16 <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEALIO3 TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE1 OZONE— POINT(GP or(5GROUT SEAL PUMPED: NYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING D HAND AUGER GROUT SPECIFICATIONSPOT Ir',A O <br /> DOTHER: D OTHER APPROX.BORING DEPTH C19 r 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specificatlons in comment section) <br /> COMMENTS: <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, Rul nd Re lations, and all applicable California State Laws. r tr <br /> Signed x Title/Company Q% I f <br /> Print Name <br /> c Date 08 <br /> DEPARTMENT USE ONLY n (/ <br /> SITE MAP IN UNIT IV FILE, ADDRESS: L-1.1%16 <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 6 Area <br /> Groh Inspection By Date Final Inspection ate <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> C-551Z WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encro/achment doe_''`` <br /> EHD 29-02-001 ✓/ 0 D(0 �-�40 C C <br /> 6/22/04 <br />