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San Joaquin County REL-76VEDD COPY <br /> ` Environmental Health Department DEC 2 9 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 M <br /> (209)468-3449 Fax: (209)468-3433 Web: www,sjgo Q "iMIL-HJT HEALTITIGATION <br /> M <br /> P NIT;H:ROCEH UNIT IV <br /> 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. <br /> � GAssessors <br /> City f� Zip S WELL Location f�6 P Cross Street ''W !b //►(y�/na <br /> Parcel# <br /> PROPERTY ( IC"'4$/r1-? 0K <br /> Owner�� 0/L Address 3/J`—,.5.c16NNSa* City6AAT0Q1U-E Zip 7 yOV3 Phone# <br /> kA4"1 d <br /> C-57 Contractor ��/'c/LCt/J _Address 37, . 0/11-65C el," City e4'4z A Zip?57V Lie#7fr510 Phone# 9/6•f`yJr 630.4Y <br /> Krpt�CHD <br /> Consultant/Sub Cntr 5�e Address 3�917 r-14000AI!CXV- City rolfAVA Lic# Phone# <br /> GIS Coordinates:X —.Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> IeNEW FIWE <br /> LL!BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER*) Q DESTRUCTION (choose type below) <br /> L BORING# Q OVER-BORE. DIAMETER <br /> LL# Q PRESSURE GROUT <br /> Q'Other ^ GROUT SPECIFICATIONS <br /> COMMENTS: (/[ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITORINGHk-elOLLOW STEM DIA.OF BOREHOLE r� Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA:______ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL Q PVC (]OTHER: <br /> Q VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: -9Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS WXAT Com' 7- <br /> 1)OTHER:_0 OTHER APPROX.BORING DEPTH ,SOI CW Q BOLTED TRAFFIC BOX or Q 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 a Regulations, and all applicable California State Law*. <br /> Signed x /1 E Title/Company <br /> Print Name G L 1���� Date <br /> DEPARTMENT,USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> iWORK PLAN DATED: <br /> Application Accepted By or Date Issued 1-61-61-7 Areaw" _ <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 f SERVICE REQUE T# INVOICE <br /> moo/ <br /> 4oA SR <br /> C-57_"C -- -WAIVER C-57 LettI of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />