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_ - Rrff'C(1,-4Vi1E . FILE COPY <br /> San Joaquin County <br /> % Environmental Health Department DEC 2 9 2'006 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br /> RS\11HEALTI�ITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgo i� , �TIS�RVICEC, UNIT IV <br /> 4`'FR`' Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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.Assesso <br /> 0160�WELL Location ro6Sof X~� C�,,e' Cross Street 0J& - GN• City - 1'4y nt Zip ?5";/0 Parcel#rPROPERTY //// '('et:I910-40K <br /> Owner KAO 0t'L Address�l S S�tIC'la/5i2h'� Cityi/Q ARTt,5(1jUE Zip yiW Phone# <br /> C-57 Contractor LU/JA Address :(3'Z ON--'C 0&J-F City Zipg557y� Lic#7f D Phone# 1/6.63f3•6/ff'? <br /> Kjpticf/U <br /> Consultant/Sub Cntr �lCr Address �OlJ r�/G/jr0 r /Q� City c7aT 3Y Lic# Phone# 91661,fj!(1,&IMO <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> PEW WELL/BORING (CPT,GFOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> OIL BORING# 0 OVER-BORE. DIAMETER <br /> WELL# 0 PRESSURE GROUT <br /> 0'Other GROUT SPECIFICATIONS <br /> COMMENTS: 3 �� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL []PVC []OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 19Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS T C�6' T <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH 510 9W 0 BOLTED TRAFFIC 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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinance Rules arld Regulations, and all applicable California State LawE. <br /> Signed xt^ Title/Company <br /> Print Name e/s L ��yfa�� /,� '-'� "> Date / 2' �y—©4 <br /> DEPARTMENT,USE ONLY <br /> 0th 9 / <br /> SITE MAP IN UNIT IV FILE, ADDRESS: t r• <br /> WORK PLAN DATED: I:x— ­6` <br /> tz <br /> Application Accepted By _ Date Issued � / Area w"01 _ <br /> Grout Inspection By Date Final Inspection By Date-- <br /> Destruction <br /> ate _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/SERVICE REQUE T# INVOICE <br /> 0/ % d.D7 SR# <br /> C-57_ C -WAIVER_ C-57 ' tte of Authorization to sign permitit/_ Encroachment doc <br /> HHD 29-02-001 <br /> 6/22/04 <br />