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oU ' n Joaquin County _] 4 V <br /> Environmental Health Department PC-c�NII�� �N SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 "` � <br /> v EMITIGATION <br /> �. <br /> " (209)468-3449 Fax: ( ) - e : www.sjgov.org/ehoJUN <br /> 2094683433 Wb2 7 2006 UNIT IV <br /> Well Permit Application SANJOdt <br /> QLtIN,COUNTY <br /> ENVIROK4ENTAL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDEALTH DEPARTMENT <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 /> WELL Location/D��. f i�13E(ZT SI. Assessors <br /> Cross Street_IA1�� TUI' City STbC*-Tnr/ Zip SLo� Parcel# ISS -02 -09 <br /> PROPERTY <br /> Owner SAO y,atq.,,A Tlc-:r�1V,10 ddress _/5-33 E. L/aPsA,/ Amity Snggrad Zip 9SyaS Phone#Czy9) 9y8-Sr(.(., <br /> C-57 Contractor CSgf a�aAbl ddress:131os WK,wwu, City brauno�J Zip 7%c6' Lic#si ttto'b Phone#(2o9)4("S - <br /> Consultant/Sub Cntr Address2-'b2,Tt.. w-Y4TLe. ST City MAifforJ Lic# Phone#S?A6) ?4S-134S- <br /> GIs Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose type below) <br /> a SOIL BORING# p OVER-BORE. DIAMETER <br /> a WELL# RESSURE GROUT <br /> a*Other G OUT SPECIFICATIONS . CcNA,.�T <br /> COMMENTS:_,-ct�,�^wA a� .3 Iuv..l+va... ..►Fws. �iNWrJ�s - s. ttkw-015-"t m-,,-pts - --- <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING p HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:------ <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS p HOSE <br /> Q AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or p 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 NOTIGE REQUIRED FOR INSPECTIONS. <br /> I hereby certif t t I h e e ed this application and that the work will be done in accordance with San Joaquin <br /> County Or es, ule Regulations, and all applicable California State Laws. <br /> Signed x Title/Company STAW FWQ4,J� <br /> IV <br /> Print Name GALS Wrap--- Date/-0(+ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 416 Ak <br /> WORK PLAN DATED: (o�7—0,6 <br /> Application Accepted By Date Issued Area <br /> r� <br /> Grout Inspection By Date Final Inspection By ` "" ate O <br /> Destruction Inspection By Date -= <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> P FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT;SERVICE REQUEST# INVOICE <br /> ZgoZ' 60 ' % SR# <br /> '2 X33 <br /> — WC -WAIVER C-57 Letter of Authorization to sigrt��JJ, pit Encroachment doc 71� <br /> EHD 29-02-001 X C/_n/`�� <br /> 6/22/04 ' <br />