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Oan Joaquin County FILE COPY <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> i (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> p " Well Permit Application 2006 MAR -3 <br /> AM Int 19 o Co <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I�Sll�p J <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work describe d 't �SI?rS$d�in compliancewi San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County EnvirrLtaji'. rTi�h6t. <br /> / n 1' 0HEMFsessors <br /> WELL Location I£S� Ei&D AyE Cross Street 6ltENA VISTA City5E0lJL 04 zip 91V3 Parcel# <br /> PROPE TYAIjL90 -r L &C6A4MAy <br /> Owner I!a 1 � rSQAddress <br /> y,cF,tl �qt_ ST•/ CitSTO`C� Zip AZ- Phone# Q f'4& <br /> C-57 ConlractorpRsp�%(( _l tt. Address 1. EAST ST. Cityyy _Zip '776 Li ex Phon p 8- f� <br /> Consultant/Sub CntrEA0-TA T" 0l4L. Address4K eIVfiL k (' City SAAj05f Lic# Phon 0 2 2- Q <br /> GIS Coordinates:>R N?7 a S 7• 3 ,p LU 121 0 11.11 ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") D DESTRUCTION (choose type below) <br /> NSOIL BORING# S H-S 0 OVER-BORE. DIAMETER <br /> 0 WELL# D PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE_ D MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> D VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ITREMIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_G OTHER APPROX.BORING DEPTH /S D BOLTED TRAFFIC BOX or D 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, <br /> Rpleles and Regulations, and all applicable Californian State Laws. <br /> Signed Title/Company ereaLOLr/ST Ta T/� <br /> Print Name �•�S Gti/ Date b2-Z1-0 <br /> DEPARTMENT USE ONLY <br /> nn / <br /> SITE MAP IN UNIT IV FILE, ADDRE S: "ce�F5& / rl— CGU ,-,j jr I�TSCIZ9 59 C'� <br /> WORK PLAN DATED: �Dl�t, �Rnel <br /> O& I IV <br /> Application Accepted By �'1JDate Issued AreaGrout Inspection By Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE Rf QUEST# INVOICE <br /> �p I 5B '9' a lD 3 . 3 SR# b <br /> C-57,,,,- WC ✓-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment/d�oc/_y <br /> EMD 29-02-001 <br /> 6/22/04 v <br />