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07/14/2006 MON 10: 03 FAX 2094683433 SJC EHD 0002/002 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .�: ..., SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> r;.. <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.siaov.orglehd 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 consiruci 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 /> p 1 /� r72r Assessor's <br /> Well Location 0�� �•Ya�Y Ae,A_q, Cross Street �OweC5 110C'r City Zip 953311 Parcel# Zn---615 <br /> Property {� n 16ZZ1 Phone# <br /> Owner 1� �hnd./l Address Po 1�UK li City �a� X. Zip r <br /> C-57 Contractor 1�cltty@r<Cu_ �i� Address 115 LaVunw�C• City a e Zip �7� ova Lic# S)15g9 PhoneU/ <br /> ui Y 0 69(0`4 <br /> ConsultantlSubCntrs�OIZ 1�•1 r �tC, Address �' �• QA. 4 UOCit qrl ova Lic# Phone 61-0 Y00 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ❑NEW WELLIBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ( DESTRUCTION(CHOOSE TYPE BELOW) <br /> ©SOIL BORING# OVER-BORE DIAMETER <br /> ©WELL# PRESSURE GROUT -4,E2 i 1'`11 10 <br /> [D'OTHER \ / 1 GROUT SPECIFICATIONS�Pa CeMekt <br /> COMMENTS: 1.WQt1�j �v �n. C7Q5�mue� l Sae, 54e. S)Ep.r'r� i ��1 LUS Z /I�C� .LC� —LEI S fi cL�fS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ❑MOMTORING ❑HOLLOW STEM DIA,OF BOREHOLE Q MULTIPLE CASINGS[)MULTI-LEVEL WELL CASING DiA: <br /> ❑EXTRACTION ❑AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING:❑STEEL [7 PVC ❑ OTHER <br /> El VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED[I AUGERS[)HOSE <br /> ❑AIR SPARGEIOZONE ❑PUSH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ❑No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: ❑OTHER: APPROX.BORING DEPTH ©BOLTED TRAFFIC BOX OR ❑STOVE PIPE <br /> CONDUCTOR CASING PROPOSI'D-- (A YES,list specit;ealions m 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 that I have prepared this application and that the work will be done I accordance with San Joaquin Coun y Ordinances,Rules and <br /> Regulations,and att applicable Califf nia L/aws./� � <br /> Signed _ — ��If�GO(/_) Title/Company - - /fJt9Pr✓!C ✓i`/ f <br /> Print Name <br /> -770-Gt� �J��j�A,7'7'[p Date <br /> P y DEPARTMENT USE ONLY I <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 00- <br /> O > E�j d / GnC�yl�l�< <br /> WORK PLAN DATED: Z VU Ifs b OQ ?) <br /> APPLICATION ACCEPTED BY ) DATE ISSUED a IS AREA <br /> GROUT INSPECTION BY FINAL INSPECTION BY DATE <br /> DESTRUCTION INSPECTION BY { 1 DATE / n <br /> COMMENTSICONDITIONS: L-U.P, h/i0 36q /4 to l r 7, G�w 5PV a,-,(-5Pv"Z_ <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE PERMIT/SERVICE# INVOICE <br /> SR#00S X52 <br /> C-57 WC -WAIVER C57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> EHD 2901 1115107 WELL PERMIT APP <br />