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U I San Joaquin County <br /> uin Coun `" �� v D <br /> a Environmental Health DepartmentEP 15 2006 SITE <br /> { 304 East Weber Avenue, 3rd Floor,Stockton,C MITIGATION <br /> (209)4683449 Fax: (209)468-3433 Web: wrww.sj jftENT HEALTH <br /> 0`I. /�RVICES 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 cunatruct and/or Install the work described. This application Is mad®In compliance with San <br /> Joaquin County, gnt Title Chapter 9 1115.3 and the Standards of San loaqu County Environmental Health Department. -�-o <br /> S A91t�. Sart Ot fj4G s,Rlw phh`�' N, f <br /> WELL Locatlon l ;, /Uuro6w 0001 Cross StrootColoaj 9. City r'pa^ Zlp q5 366 Parcel# <br /> PROPERtZ <br /> �UY^ - 6 "r�" 0,2- <br /> owner <br /> � <br /> Owner ' Address Ye- p-Io-QV, City � Zip PhoneNr <br /> c. s <br /> C57Contractor RSl Dr; 111 Address ciryUUlondzlp9r� tsuc# Phone S30 ahR-aya <br /> Consultant/Sub Cntr L tv(��Q� $ne , Address � City c G!7 LIQ n/� Phone P3 Vto)U <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING `cPT,GE Q R BE,HYD NCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> -*SOIL BORING# -j Ytp12 �l// U OVER-BORE. DIAMETER <br /> n WELL# [I PRESSURE GROUT <br /> srOther orGROUT SPECIFICATIONS <br /> CQMMI NTS: T ;— 3 Ylales •fes C� W, to«cl��,'1l w� Ceih o4 <br /> TYPE OF WELL INSTALLATION TYPE OQNSTRUCTION SPECIFICATIONS <br /> o MONITORING Q HOLLOW STEM DIA.OF BOREHOLE",j,�,a MULTIPLE CASINGS []MULTI-LEVEL WELL CASING DLA: \ <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS _ TYPE OF CASING: D STEEL U PVC d OTHER: <br /> ❑VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE PUSH POINTor CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE-T=ALL DEPTH IS 30') <br /> SOIL BORING Q HAND AUGER 0 GROUT SPECIFICATIONS e fYlk.'r1� <br /> OTHER: OTHER APPROX.BORING DEPTH_ 30 �40 BOLTED TRAFFIC BOX or Q STOVE PIPE (, <br /> Woc�r N o� CONDUCTOR CASING PROPOSEDv <br /> (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 th tI have pared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinal s, a s d Regulations,and all applicable California State Laws. <br /> signed x � .' �^ Title/Company 1!�-:6 o'([,11 )A SIC <br /> Print Name <br /> 0'-i't71- Dat 1106 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 ,5-6L(0 J:F. Sol In',c,S 0 V__C. <br /> WORK PLAN DATED: D <br /> Application Accepted By Gtr Date Issued .1 2 Are u <br /> Grout Inspection By U� t ewe Date 'I 1Zk Final Inspection By Date Z-1 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> [COUNTING ONLY: AID# FAC# <br /> CODES FEE INFO AMOUNT REMITTED CHECK# REG'nBY DATE PERMIT(SERVICE REQUEST# INVOICE <br /> 9a1 ��o� 05 5� Gk q o� SR# 4SZZ� <br /> C-57— WC_,-WAIVER C-57 Letter of Authorization to sign permit—Encroachment doc�_ <br /> EHD 29-02.001 <br /> 6122/04 <br /> Za AOVCJ SZ90SE863Z SZ90SE86OZ TOOT 90OZ/6T/60 <br />