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NLECOW1W 0 0 <br /> NOV 2 0 2006 <br /> ENVIRONM ALTH San Joaquin County <br /> PER 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 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the wrk described. This application is made in compliants�n c.,.. <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of SSann/Joaquin County Environmental Health Department. <br /> _ Assessors /4WELLLmlifon SoST%LLeib` QrCross Street aY -5-fA1P�SZ176ParcaF# -1-7f6-Os' <br /> PROPE <br /> Owner - AddO . <br /> �OPhonelf /t * <br /> C-67 Contractor TGC City AnWyl jp4S7Kiq��sphone# U6u <br /> 53$ CC) <br /> 40 M a <br /> 7 dress 2W� City46aij(, c# From <br /> Consultant Sub Cnr _ C _ e# <br /> l <br /> GIS Coordinates:X 'Y Township Range Section <br /> )MORK TO BE PERFORMED.- ' <br /> EW WELL/BORING (CPT, EOP HYOROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choosetype below) <br /> 0 SOIL BORING# Y OVER-BORE. DIAMETER <br /> g WELL# Z RESSURE GROUT <br /> U-Othar GROUT SPECIFICATIONS <br /> COMMENTS: Z ' p r <br /> rz <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE211 B MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA' <br /> 0 EXTRACTION g AIR HAMMER/ORIVEN CASING THICKNESS Iltf TYPE OF CASING: p STEEL 0 PVC p OTHER: <br /> 0 VAPOR 8 MUD ROTARY DEPTH OF GROUT SEAL—I&' ^30' TREMIE TYPE TO BE USED:. DAUGERS gHOSE <br /> g AIR SPARGE]OZONE,�PUSH POINT(GP or CPT)GROUT SEAL PUMPED: lives p N1NFAT IMUM �PTH IS 30') <br /> )Jr§OIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH u BOLTED TRAFFIC BOX or g STOVE PIPE <br /> ,, CONDUCTOR C SING PROPOSED (if YES,list spec/Ncalio in comment section) <br /> COMMENTS:_ T j�J.yr 6��f{Pgt • •?-�J- /^— ^1AAW <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord//T�'�fRf'jJrn/a/g/ Rul and Regulations,and all applicable California State Laws. <br /> Signed x 27/,� '1��w�,l.4 Tme/Company_�i.F <br /> Pint Name_01 L-� 4&,Dw Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DRESS:. <br /> WORK PLAN DATED: 111161 Zo O6 <br /> Application Accepted By _Dale Issued I I Zt O Area <br /> Grout Inspection By 1ANgA4ArMA Date Il 3U Ob Final Inspection By1 - Date—Lt 30101, <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> LECOES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> l #£5s`I (7411140�1� (c( I,(7-,'O6 SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122,W <br />