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INd <br /> a Oath San Joaquin County <br /> ° Environmental Health Department SITE <br /> t 304 East Weber Avenue, 3rd Floor, St' ck.on,CA 95202 MITIGATION <br /> } E 9)468-3449 Fax: (209)468-3433 We" •vrvu,.,icov.xg/ehd U N I T IV <br /> Well Permit Application <br /> SEP 2 7 2006 NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San oaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaque�l to <br /> 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> p����rx�lC Assessors 110-210-04 <br /> WELL L6c4{itllyr 'aMourt Cross Street N.Pershing city Stockton __zip 95207 Parcel# <br /> PROPERTY 95267- (209)478-2060 <br /> Owner Stockton Hospital LP Address PO Box 7343 City Stockton Zip 0343 phone# <br /> de Drilling Inc. R+Lr^e k o <br /> C-57 Contractor CAddress3b��-G1rC�e CiryCorcta�w- Zip`10/4uc#1l75I0phone#_(916)638-1169 _ <br /> 2285 Morello Ave. Pleasant (925)602-0710 <br /> Consultant/Sub Cnlr-ETIC Engineering,Inc. _Address City_Hill,CA Lic# Phone# <br /> GIS Coordinates:X 'Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) R DESTRUCTION (choose type below) <br /> E SOIL BORING# ROVER-BORE. DIAMETER.1'10"to 3 ft bas <br /> 0 WELL# &PRESSURE GROUT <br /> 0.Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> R MONITORING E HOLLOW STEM DIA.OF BOREHOLE.10" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL R PVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL - TREMIETYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH_44' 0 BOLTED TRAFFIC BOX or 0 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 prep red this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules an egulations, and all applicable California State Laws. <br /> Signed x_-<a-et!�rul _� Title/Company CO.F,C-ZA'e I.)n11,(V1.0� I' r)C <br /> Print Name E✓vyi-s"1L I/L-�('e. Qa 0 —oto <br /> Date <br /> ,ff DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: `t4 Li L{ S1/-x. <br /> WORK PLAN DATED: � y P <br /> Application Accepted By /� Date Issued 9f a4f 0J ' Area ?e?7 <br /> Grout Inspection By Date Final Inspection By —Date— <br /> Destruction <br /> ateDestruction Inspection By Date/0 I Z bo <br /> COMMENTS I CONDITIONS: S P. ,la.-.. J' �J - "L b OP S <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ©1� �b°O fib° d o88�d 9 L9�b� SR# Ob �Z3 <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 />