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or <br /> kW 0\1 San Joaquin County U L' <br /> nvironmentai Health Department SITE <br /> f� <br /> It Weber Avenue, 3rd Floor,Stockton CA 95202 <br /> MITIGATION <br /> gf4 <br /> 48-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> LINA 5 2006 - <br /> Well Permit Application ��, - <br /> ENVIRONMENT } IFrfUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is herePjE#WTr NC3M 8 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 8-111115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location Cross Street (�dr�h 64- City Y'-k l4P-CGI. Zip ',33G�Assessors <br /> Parcel# 223~(pl I - 0 <br /> PROPERTY <br /> OwnerSGa D` lX t 1�rt711; Address. P O L20 (D Z7 city i\ACCrt 12cg.zipl Phone#-(Z C'C1 �- I {) <br /> C-67 Contractor =0dlt Cn11ldress PE). 33(o cityLt d Zip416Lic# Phone# (707 14 12 <br /> su t/Sub Cntr_ ji CQ` 1P W),.c S Address 1 tD t � r CIty-NV0A0;i0 Lic# Phone#(ZC�i���j 2 Z [cl <br /> GIS Coordinates:X 'Y Township __ . _ . Range Section <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> []SOi`LBORIN # ��p OVERBORE. DIAMETER <br /> 0 <br /> Q PRESSURE GROUT <br /> Q`Other 11 GROUT SPECIFICATIONS <br /> COMMENTS: - C& C- iJ�l i� tQ r <br /> TYPA OE WEL IN§TALLATION 3nE CONSTRI„1CTION SPECIFICATIONS <br /> ONITORING <br /> PE IFI- TIONS <br /> ONITORING OLLOW STEM DIA.OF BOREHOL Q MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA: _ <br /> �Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEELyPVC Q OTHER: <br /> 11 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE UI(ED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> 0 SOIL BORING HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: /n_OTHER._-_ APPROX.BORING DEPTH 1]BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> ` CONDUCTOR CASING PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: �Q ��AG` LJ� . �Cl�l `� Lis <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 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 State Laws. <br /> Signed x �^ c ,gip Title/Company V i� r- <br /> PA 909 - <br /> PrintName Yco-r h1rC Nt E Date DS-3b-ot; <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: A) <br /> WORK PLAN DATED: 116--'30 O 5 <br /> Application Accepted BY A Date Issued +' cArea �v <br /> Grout Inspection B Date <br /> P Y l& Final Inspection By-- ---Hate <br /> Destruction Ins ection By Dake <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57—k/- WC�-WAIVEk C-57 Letter of Authorization to sign pertni W-ImEncroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />