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eSan Joaquin County REW v ED <br /> Environmental Health DepartmenttUL 1 4 2006 SITE <br /> w < <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sj?&M ENT 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 iy,5-c�.2-)_3 <br /> WELL Location K✓29 ¢aI35 Wc541(n -Ycn L4. Cross Street N"Lv r City J(f0r✓/7foq Zip %,5a[/3 Parcel# /`JS'a;L <br /> PROPERTY <br /> Owner Pcr)e-52fo<,A-16,1 Address Wa-5h,n4fog City or-Afon Zip 35WO phone#A6, -I`16.O+,-l-6 <br /> C-57 Contractor 1 4=G Address II350 Mm(ty P4r'c ?11K City RqN ;" Zi. 157Y2Lic#10b%S Phone#RIG"03-SO)g <br /> Sf C.3S0 <br /> Consultant/Sub Cntr 'Erun Address 25,75 Nato,;,, P6,-li,Or.City Scrr,,, ,,A Lid# Phone#'/6-9a Y-4379 <br /> GIS Coordinates:X ,Y ,TownshipSPb 6[ Mr, plu.-blo <br /> n b' Range Section <br /> WORK TO BE PERFORMED: 644 e,< Mer,01,E n <br /> 'XNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 11 DESTRUCTION (choose type below) <br /> ASOILBORING# SA-e /'o .56-Ad aOVER-BORE. DIAMETER <br /> p WELL# a PRESSURE GROUT <br /> )]'Other �/ GROUT SPECIFICATIONS <br /> COMMENTS: 13 ,io:"/ horin 5 C O/' ynVP5fi9u."><i an !O -`"/a r Aa/y� aro,�a / SU.r Qct <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> fl MONITORING p HOLLOW STEM DIA.OF BOREHOLE2_5'�0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS 1 e TYPE OF CASING: 11 STEEL XPVC 0 OTHER: <br /> a VAPOR u MUD ROTARY DEPTH OF GROUT SEAL /2/ TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE ](PUSHPOINTGP rCPT)GROUTSEALPUMPED: a Yes XNo (NOTE: MAXIMU M FREE-FALL DEPTH IS 30') <br /> SOIL BORING fl HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_n OTHER APPROX.BORING DEPTH /A I a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: PV'- r-45/nc, 4,01 /9E'. In.S�a/Pv7 �O/' moray_ a4,/1rs 4nll -I'Af4 5/10// de- rP. OVd 9Well <br /> c/r'.�;i rogeG. <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 u ns,and all applicable California State Laws. <br /> Signed Title/Company C6� - rneLj , I,ve 5�, IAC . <br /> Print Name MA Gln/ A - Date 741(-ob <br /> �7DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:�3 / / <br /> Application Accepted By 0k� Date Issued 7117 10,4 Areae <br /> Grout Inspection By Date l r� b,� Final Inspecfion By Date <br /> Destruction Inspection By Dat <br /> COMMENTS I CONDITIONS: C V P_L+� <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 0(o1 �y' �i giS�Z (JI- 11/i ojo SR#0C) 115 7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 6/27/04 <br />