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_ FILE CopyYMEN- <br /> San Joaquin County RECEIVED <br /> ,, Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 ApR 0 3 2006 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd <br /> JOAQUIN COUNTY UNIT IV <br /> SAN <br /> Well Permit Application ENVIRONMENTAL <br /> DEPARTM <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 /> Assessors Ct <br /> WELL LocatioruZCross Street rant rine Ocity Tr Zip —" Parcel# Df–(76. 8 <br /> PROPERTY <br /> Owner70?UI11IQrL Iti)QChado Address 175Z W. 61fant Lin[Acity TfQ tr Zip 1 530 Phone# — <br /> C-57Contractor Gtrreg4 DtIl�_Address 950 Howe M. cityMar6rz. ZipjU3 Lic# Phone# <br /> Consultant/Sub Cntr 5A[C Address I Otto Broad u4 u. St. ' City Ocl k Lic#K 5 3 I q Phone#'5I <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 'gNEW WELL/ BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> 0 WELL# 0 PRESSURE GROUT <br /> []'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE " 0 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <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 TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 'PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> `;SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Fen+O n I f e <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH a25 I 0 BOLTED TRAFFIC BOX or []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 ave epared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, ule d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company SCARIC ef'l L t!W&Wl- . CAI C-- <br /> Print <br /> Print Name YVA C –1– Date 3131--0)10 <br /> DEPARTMENT USE ONLY �/ ,, / <br /> SITE MAP IN UNIT IV FILE, ADDRESS: '< �� <�Gta/ AM Gi0"d, ttC <br /> , , <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued '0 6 Area to <br /> Grout Inspection By Date Final Inspection By --?ate <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 REQUEST# INVOICE <br /> moo/ "- 2 �r 3 SR# 24 <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 />