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0 HEAVED <br /> San Joaquin County <br /> r Environmental Health Department UL 1 4 2006 SITE <br /> " { 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www-sigaMOMENT HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVICES <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 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 /> /' Assessors IIS-O.7-13 <br /> WELL Location-i,9;0 42135 Wc5hiu540�Cross Street A&V4, (r City JfOC At�on Zip `'�5oZ03 Parcel# /c75-oz- 9 <br /> PROPERTY ;'A6 uJ, wG, AAn Zip G5203 Phone#;Rog- "6-(J9�/-6 <br /> Owner �o�l"�,Sl-foUffi!`on Address 1 S�ii c�G� City .cifac n <br /> C-57 Contractor 1 1�[-� Address 11350 HM�ev pak f 14,c City 2 eVq Zip9S712 Lic#1gb�{1V Phone# <br /> Ste,3SU <br /> Consultant/Sub Cntr ��7�1 Address A5.75 Natomns Pa.rk6.CIty5Q,,, Lid# Phone#9/6-9zy-5378 <br /> 6E M . O wb/o <br /> GIS Coordinates:X 'Y ,TownshipS6,cAion Range Section <br /> l�Gs2 C Me.rj of%c,rl <br /> WORK TO BE PERFORMED: <br /> 'ZNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') E DESTRUCTION (choose type below) <br /> ,)}SOIL BORING# S,g-IA fb .56-X6 DOVER-BORE. DIAMETER <br /> 0 WELL# u PRESSURE GROUT <br /> a*Other �j L[ GROUT SPECIFICATIONS/ <br /> COMMENTS: /3 ,io"/ ho'/ir s, 5 KO/' <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING E HOLLOW STEM DIA.OF BOREHOLE 25 E MULTIPLE CASINGS E MULTI-LEVEL WELL CASING DIA: <br /> E EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS r TYPE OF CASING: 0 STEEL PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL /d/ TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ]'PUSH POINT GP)or CPT)GROUT SEAL PUMPED: 0 Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .JrSOIL BORING aHAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH /a/ BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: PVC- L4-5/nc, Will b�- /n.5�a, ��� �O/' A,D2�0y_ dy.�i^� 4.n,,I� 'ftiw4 JII/C 5,4c,// P_ rlmoyec� i�WC <br /> o1e..1-r6re�% <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify t t I h prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin ces ufa ns,and all applicable California State Laws. II <br /> Signed �i Title/Company Gbl e5i — E�/ �ye ftr fits <br /> Print Name !• -' UA/ A - Sr meet I K eU / Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: d—/ W- �Q� ��— <br /> WORK PLAN DATED: <br /> �/7i.._?� �/ / <br /> Application Accepted By �d'(�/ � ItDate Issued Area <br /> 7/Ob Area, 4? <br /> Grout Inspection ByDate 1 D to Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: C U IZl✓Q L <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> A101 89' 8'� " q5 -2-77IV,- 11/m/pp SR#00 I/Z/7 <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 />