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On Joaquin County � • <br /> Environmental Health Depart[U�C G w�U SITE <br /> { 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgcdCoTg/jh® 2006 UNIT IV <br /> Well Permit Application ENVIRONMENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE'a98W6FRACES <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 rhapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> . Assessors <br /> WELL Location-3;q • (`!J(JGl �rJ Cross S,tr^^eet �.'�A�/ � C ItyL' S� -1'LZip Z-Parcel# <br /> PROPERTYc � T`S LN��I�ooL <br /> Own Address ,,te� 1�I� ityS� �'�Zip 4 _Phone# 11/J �/7 <br /> C-57 Contractor 9' Address%q IMC Cit P.Z.Zip�lic#66b"hone# 313 69cn <br /> Consultant/Sub Cntr ,�Sl:-i�L7Y{.J�'clK.ys4 aa8dnss�°�p�.��1' "¢�ts� City b�t'`�'•9 Lic#�'-�(pOPhone# S"I7�'�x'9987` <br /> GIS Coordinates:X_ ,51'I Cg&5'Y a,g� I 01 t.4 ,Township 1 Range._Section L <br /> W RK TO BE PERFORMED: <br /> NEW W LL/ BORING,1 11( �1 GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> < O!L BORING# -Ft- 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> I]*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING (I HOLLOW STEM DIA.OF BOREHOLE 1 ZEZ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:tJ)A <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL r I Pr TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No NOTE: MAXIMUM FREEFFALL E ) <br /> []SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS C44-r\e a-/' <br /> []OTHER: []OTHER APPROX.BORING DEPTH 1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED t— (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 ertify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O e Rules anc R gulations, and all applicable California State Laws. <br /> Signed x Title/Company <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> C <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 41 3 J <br /> WORK PLAN DATED: I IT <br /> Application Accepted By :� t Date Issued IQ / Q Area <br /> Grout Inspection By Date _Final Inspection By <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/SERVICE REQUEST# INVOICE <br /> 35a 1 � a� /6 /6116 SR# 4$9s <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />