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03/09/2006 34:27 2094683 . <br /> END PAGE 02 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> f209)458-3449 Fax:(209)468-3433 Web: ❑vww.sjgov.arg/ehd UNIT IV <br /> " Well Permit Application - <br /> NON-REFUNDABLE PERMIT EXPIRES I Yak FROM DATE ISSUED <br /> Application is.hereby made to.San Joaquin County for a permit to construct and/or install.the work described. This appllcatlori is made In compliance with San <br /> Joaquin County Development Tltte,Chapter$0 115.3 5�n d.tho� dards of San Joaquin County Environmental Health Department. ! <br /> (� r q k, �ff e� Assessors n� <br /> WELL Location�00© E SF l° Cross traet 9 4- City. 60c tvr Zip.9uVT7 Parcew# C4Z_TP ,,VS <br /> PROPERTYC../41 7$2 41VS <br /> Owner Address C1 —,Zip. Phone# . <br /> C-67 Contractof -C c). Df'kAA Address j5_D f�t�_�. city�i'dg��'p,` 3Llc� r��hone# 3t3 y5-8"00 <br /> Consultantfsutiontr Z�1& Asac.4AIJ Address 130 Z gAe., S. city�� io# Phone# =77�-0907 <br /> GIs Coordinates:X _ _ _-,Y Township _- -- Range Section <br /> WORK_To BE PERFORMEPi <br /> NEW WELT»/BORING...(CPT,GEOPR08E,HYDROPUNCH,HAND-AUGER,OTHER-) ESTRUCTION. .(choose.type below) <br /> a SOIL.BORING.#. OVER-DORE..DIAMETER <br /> p WELL# RESSUR6 GROUT <br /> p"Other _ GROUT SPECIFICATIONS <br /> COMMENTS', <br /> TYPE OF WELL INSTALLATION TYPE: CONSTRUCTION SF�CIFIGATIONS <br /> MONITORING HOLLOW.STEM $" 01A.OF DOREHOLE U MULTIPLE CASINGS 0 MULTI-LEVEL. WELL CASING DIA' <br /> /13 EXTRACTION U.AIR HAMMERYDRIVEN CASINGTHICKNESS� 'TYPE ORCASING: a-STEEL d PVC R OTHER-. <br /> [I VAPOR a MUD.ROTARY DEPTH OF.GROUT SEAL TREMIE.TYPETO BE USED; U AUGERS u HOSE <br /> [l AIR SPARG>E1..OZONE 9 PUSH POINT(GA.or CPT)GROUT WL PUMPED; Yes ..`Q No (NOTE:.MAXIMUM FREE-FALL DEPTH'IS 301.) <br /> 11 SOIL BORING. a HAND AUGER GROUT SPECIFICAMONS <br /> p OTHER: I]OTHER .APPROX.BORING.C]EPTH a BOLTED.TRAPFiC BOX or 0 STOVE.PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications.in comment Section) <br /> COMMENTS: , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS,NOTICE REQUIRED FOR INSPECTIONS. <br /> 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 Stat6 laws. <br /> Signed Title/Comparry �rtv�ibnMG. � T nr�•fn-, — C.���� J�c•� <br /> PrinlName ///� vDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP.IN.UNIT N FILE,.ADDRI S5§: <br /> WORK PLAN DATED: <br /> Application Accepted.BY ��+" ^^! ` Ue Issued <br /> Grout inspection By Dote F Final Inspection By. .Date <br /> Destruction Inspectlon By -.1 Date <br /> COMMENTS 1 CONDITIONS: S L-0 P <br /> ACCOUNTING ONLY; AID# FAC/1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK* REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> SR9 t)04k LL02 IttroIlf <br /> C-57_ Wi -WAIVER— C-57 Letter of Authorization to sign pertnit_Encroachment doc__ ; <br /> WM -02-Wl <br /> J71 �C - zoom � AV 0(0 <br />