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79/29/2006 14:57 209468:` EHD 3 „s PAGE 02 <br /> *VrEir <br /> San Joaquin County $ITEEnvironmental Health Department304 East Weber Avenue,3rd Floor,Stockton,Cog202 MITIGATIUNIT NON <br /> 9)468-3449 F=(209)468-3433 Web: www-$jgWell Permit Application <br /> sQ & 7 ZOVt1 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAYE ISSUED <br /> Application tats h to S n hapte C9-1116.3 and the Standards of San Joaculn County Environmental Hlealth application <br /> in somplin210-0 San <br /> GG Assessors 110-210-04 <br /> Joa9 ocIMF*�N.G N.Pershing Stockton -.–Lrp 95207 Parcel# <br /> WELL L3da9URt Nt'r`----" ours Cross Street C'�' <br /> 95267• (209)478.2060 <br /> PROPERTY Stockton Hospital LP PO Box 7343 city_Stockton 210 0343 Phone# <br /> Owner Address (L&r Cko <br /> inc. 3 'x2 crr 'C,:ii '-dtits City aDrAaVP- ZinyS-T4d udk'"1175fOPhonEi!-(91 66� 38.1169- <br /> C-57 Contractor C°scade Drilling Address pleasant (925)602-4710 <br /> 2285 Morello Ave. CdY_R'11 CA Lie# Phone# <br /> Consultand I Sub Cntr_ETIC£n 'nee .Inc- Address <br /> GIS Coordinates:X ,V�_ <br /> Township Range Sermon <br /> wows 70 B ERFORME DESTRUCTION (choose type below) <br /> Q NEW WELL!BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHERS 11 OVER-BORE DIAMETER.110 p•3�ft� <br /> Q SOIL BORING# &&PRESSURE GROUT <br /> U WELL# ROUT SPECIFICATIONS <br /> U•Other <br /> COMMENTS' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE-]0" Q MULTIPLE CASINGS n -LEVEL WELLCASING OL4:_�' ._ <br /> U EXTRACTION U AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: U STEEL R PVC Q OTHER: <br /> U VAPOR n MUD ROTARY DEPTH OF GROUT SELL TREMIETYPE TO BE USED: U AUGERS 8 HOSE <br /> Q AIR SPARGE(OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED, n Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> Q SOIL BORING U HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> U <br /> Q OTHER: OTHER APPROX.BORING DEPTH_ U <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in commend 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 prep d this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules an egulations,and an applicable Califotni�te Laws. <br /> signedx •. 1. �•i TiUelCompany <br /> rr <br /> Print Name— 1 I/L• ` Date <br /> `fin' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued �r a`� Area 997 . <br /> Application Aooepted By Date <br /> Grout Inspection By Date Final Inspection By <br /> Destruction lnspecfion Date �p 1'L D(� <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY! AID# FAC# <br /> PE CODES FEE INFO AMOUNTREMITTEO CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> (abs av 9 s91a SR# Ob 3 <br /> C-57.` WC;WAIVER— C-57 Letter of Authorization to Sign permit!,Encroachment doc_ <br /> rM 29-02-001 <br /> 6/22104 <br />