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FILE COPY <br /> San Joaquin County <br /> zEnvironmental Health Department SITE <br /> 3 0 2006 <br /> 1 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> I <br /> ..C)NtOEN(20�4143449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> M 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. lv� <br /> WELL Location /O�+J, -4/ 6��� eCross Street Mfn �0 City A h U ip 5 6 Parcel# r__2L0j---4 -12- <br /> PROPERTY <br /> 12PROPERTY //�� I��,rr J, /� /� <br /> owner K4812-DUVE16A, Tib Address/D7q�/•.�12>AIrT 1Wf1by �T6Wt Zip4q 391 Phone# �[� <br /> C-57 Contractor V/fin Address5292 CH S. City�ACkF.Gc) Zipqyr <br /> ic# Phone# VS-521'1y90 <br /> Consultant/Sub CntrJFtIC. Addressr//(�MIKIWIV. AN CityAKLA41D Lic# Phone#514433'6835' <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: �---� <br /> NEW WELL/BORING (CPT. EOG PROBE.NYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> SOIL BORING# a OVER-BORE. DIAMETER <br /> 0 WELL# J a PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Q HOLLOW STEM DIA.OF BOREHOLE f n a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a MUD ROTARY DEPTH OF GROUT SEAL 231 TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> a AIR SPARGE/OZONE APUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: V,4rU� LIJT 0 OTHER APPROX.BORING DEPTH A23 0 BOLTED TRAFFIC BOX or a 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 certi th I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orli n , R es and Regulations, and all applicable California State Laws. <br /> Signed x v Title/Company Sl�u� T X20)SCT MAt! f CoiL <br /> Print Name A CNAQe 4V%Z0 Date 1��29eDL <br /> D`E'P'AR�TMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: „//'tQ-�—oa (v w G <br /> WORK PLAN DATED: <br /> Application Accepted By Date IssuedArea <br /> Grout Inspection By Date Final Inspection By � to <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE RREQUEST# INVOICE <br /> SR# Q A0 <br /> C-57 VWC=WAIVER_ C-57 Letter of Authorization to sign permit_Encro ent doc� <br /> EHD 29-02-001 <br /> 6/22/04 Az�e-4� <br />