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MAY. 19 '2006 10:21 8586379201 USG:' #7a03IT <br /> � <br /> 1 u <br /> San Joaquin County <br /> •' � PY <br /> Environmental Health Department SITE <br /> 304 East WeUcr Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> •^ (209)468-3449 Fax: (209)468-3433 Web: www.sjgov,org/ehd UNIT IV <br /> c . <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 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 /> 1 Assessors <br /> WELL Location JIT, ^61 ross Street 10-H1 .z' City�7o��{flD IJ Zipl�s Parcelit o1�-�/ <br /> �4�2'A/ '0A.vr /3raq//rs OQJ <br /> C'ay.v 3�/-�2be?1 c%QrE; <br /> PROPERTY � J/7¢3 <br /> Owner \,V,wy �bG�uI Address I�t t' ity Z0�� ZfpgSelYyPhone ��/ �S3• g(�b0 <br /> ddressy/GS�SQj���e ity�Zip9o�/a/I ic# 44-Phone#fj/9 oN.j-(w/\j,• <br /> Consultant/Sub Cntr Address City U0 Phone# <br /> GIS Coordinates:X_ dC 63 /S ,Y_1A Township 4 A/ Range ,-,C- Section 01 <br /> WORK TO BE PERFORMED: <br /> @NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> 00IL BORING# []OVER-BORE. DIAMETER <br /> 0 WELL# (]PRESSURE GROUT <br /> a*Other GROUT SPECIFICATIONS <br /> COMMENTS: 2 �rR rd//rad C,r4 e - r0 AF asvR a cn ors yf-a Sf at <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING OLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_ ^ TYPE_OF CASING: 0 STEEL n PVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS [J HOSE <br /> []AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: G-les [l No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,Qig'6IL BORING 0 HAND AUGER GROUT SPECIFICATIONS .S`v <br /> a OTHER: 0 OTHER APPROX.BORING DEPTH 0! - _ []BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Al o - (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 /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances ules and Regu a 'ons, and all applicable California State Laws, <br /> Signed x Title/Company_A p ineA D/b1C/s"f <br /> Print Name Date_ u ✓ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: U.56S - C iIl� <br /> WORK PLAN DATED: G <br /> Application Accepted By Date Issued5rlv Area_ <br /> Grout Inspection By _Date O(a Final InspectioDate 7—zk--O_(o <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 I SERVICE REQUEST# INVOICE <br /> SR#e 3b <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doe_ <br /> EHD 29-02-001 <br /> 6/22/04 ®W �i <br />