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*an Joaquin Gouniy FILE COPY <br /> Environmental Health Department SITE <br /> " 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgo�RR d9FWEe UNIT IV <br /> c,FORa�P Well Permit Application <br /> JUN 1 2006 0 N -415 <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work des&NWRj Ha4EhAKe in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environr"RkM®I�i�'Ttgl91t. <br /> �y�� Z '�7 Assessor <br /> WELL Location �V%/J GI I'1 /iG'li1,VN f t.• Cross Street\� tf city Zip yr"ZParcel# <br /> ✓ r <br /> PROPFR <br /> Owner. T _-C�Lf G(✓-LIn4 dress �fJ" T. Cit�'�• ZiF phone# <br /> C-57 ContractorJDyhffiM ftpb ��lddress l-36 W 1 WMn ✓r rl/GCitY.]I r(, ✓� Zip lic#s I hone# Y IiL <br /> tt"""1'�1"1' � <br /> Consultant/Sub Cntr�YT/fit (��t __Address V ` 1Ci � {(bc# r Phone#roG5/ (� <br /> GIS Coordinates:�X�iy Yt " -y Township � N Range otoL.- Section <br /> WORKTO BE PERFORMED`1�`" RI I(7 V't � 5t0' JIB." T <br /> ^gNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) D DESTRUCTION (choose type below) <br /> 0 SOIL BORJN�G# _ 0 OVER-BORE. DIAMETER <br /> WELL# FAY^J�l.� _ _ _ D PRESSURE GROUT <br /> 0`Other " '� GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �1 it <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLEh&' <br /> 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:=L__ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS. '- ` p/TYPE OF CASING: 0 STEEL ` PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 'dAUGERS D HOSE <br /> 0 AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes �KNo�(NOTE: MAXIMUM F-RELL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 3 �J ligyYlt ll UYfV. 'E-FA- <br /> 0 OTHER: fl OTHER APPROX.BORING DEPTH_2 2, 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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina,fncJes, Ilre—/s a Regulations,and all applicable California State Laws. 1 i <br /> Signed x �w J 6 �d Title/Company ✓lam <br /> Print Name S D Date <br /> DEPARTnMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESS: / Cu✓LW �D <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued CO 'z':5 6 Area <br /> aw- <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> S <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit-4 Encr ment doc_ , <br /> EHD 29-02-001 Q <br /> 6/22/04 <br />