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INOHEUI M�lu f 0 <br /> NOV 2 0 2006 <br /> ENVIRONM #EALTH San Joaquin County <br /> PER r. : Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> ( . (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the wont 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. /63-76,0-ev <br /> Asse6sors <br /> WELL Location 1q"A.16e GP1.P:c 6e. Cross Street_&4*%, City ip cbzul, i# <br /> PROPE <br /> Owner Ass &9f _Adtlress ciRO S /hK-St<�iCm spv' Z1pa DrPhona# ///S Z37-8SY0 <br /> C-67 Contractor- TI.'C'_t ,o.� _Address I13SV Y✓lowyntQp..�Jop) C61 RP,wcl'w 6. _gPhone# al6853 Solo <br /> Comulfara/Sub Cntr eTlIGo4 Address w.as. Iry irx 5 � Phone# 704-.TY3—�-f 22 1 <br /> 018 Coatlinates:X ,Y ,Township Range Section <br /> PMRK 0 BE PERFORMED: <br /> EW WELL/BORING (CPT, EOP HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# tF a OVER-BORE. DIAMETER <br /> O WELL# Z ]WRESSURE GROUT <br /> a'OU*r Garr SPECIFICATIONS <br /> COMMENTS:.? se: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING n HOLLOW STEM DIA.OF BOREHOLE?,10 MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> ___A <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESSl7c _TYPE OF CASING: a STEEL a PVC a OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL I C"e/30 TREMIE TYPE TO BE USED: a AUGERS 0 HOSE <br /> 0 AIR SPARGFJ OZONE jkPUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes a No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> �yOIL BORING D HAND AUGER GROUT SPECIFICATIONS h„�L^'�� C(D6nl!EA)1r <br /> 0 OTHER'_G OTHER APPROX.BORING DEPTH D BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR C SING PROP�O/sED (if YES,list spatlficaeo1,11 m commam section) <br /> COMMENTS: T <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 prepared this application and that the work will be done In accordance with San Joaquin <br /> County Ord' nce Rul and Regulations,and all applicable California State Laws. <br /> Signed x _ Tiue/Company <br /> Print Name LE'" ,A Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I LI $ T\.i.�.r�r_ I�Nh h-' <br /> WORK PLAN DATED: l� ( t 6 I 2oofi <br /> Application Accepted By Dale Issued l 172 Of, Araa <br /> Grout Inspection By W14 AA A"..... Date I IP40r,I - 40r, Final Inspection By Data �n <br /> Destruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> z°lol $8q.00 �S�`1411dI1 (Alt tt z �(, SR# gC�Lj <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD29-02-00I <br /> 6/22104 <br />