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09/08/2006 07:44 FAX 9166792900 <br /> URS-SACRAMENTO-GO <br /> 002/004 <br /> u <br /> San Joaquin County <br /> Environmental Health Department <br /> i 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 SITE <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd MITIGATION <br /> 1WUNIT 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 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 /> WELL Locatlon .2_�7 b.(�G(4P 1 C,,7,n'� SCA"t;"v 4. <br /> Cross Street CAP-U'& j Assessors . <br /> PROPERTY _ b'VAS —_►� Ci ZIP �F' Parcel# ZS ZD-]Dd Z <br /> Ownerl�5 CoC✓�t� 3 t'W i 00 P-M.'L- <br /> ,A1s�'1- Address2L�ipy�CNaf.S%.aJ nr`i r <br /> tyZip Si 7l.Phone# - Zj�-Z33a <br /> C-67 Contractor� j�"44"k'6 gddress_t /Jp gyp. <br /> City11►A/:7frvfi�Zip 533Lic#( d Phon 925_ 3/3$ 3aD <br /> Consultant l Sub Cntrt/!!� p R jC�a T7- <br /> Address2�'7b �,��., a. <br /> G15 Coordinates:X <br /> _Lic# Phone*_,T L j p <br /> _747F�i�-f-161�1'� <br /> �� ,Township --�� Range_ <br /> WORK TO BE PERFORMED: Section <br /> 0 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose <br /> baOIL BORING#_ ) <br /> 0 WELL# Grp fes'-oU07Z p OVER-BORE. DIAMETER ty� <br /> 0*Other 0 PRESSURE GROUT <br /> COMMENTS: 5't� GROUT SPECIFICATIONS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE <br /> 0 EXTRACTION 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL D STEEL 0 PVC 0 OTHER: <br /> 0 AIR SPARGE/OZONE�P.USH POINT(GP o PGROUT SEAL PUMPED: TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> 0 SOIL BORING 0 HAND AUGER p Yes p No (NOTE;MAXIMUM FREE-FALL DEPTH IS 30') <br /> GROUT SPECIFICATIONS <br /> 0 OTHER: $' <br /> 0 OTHER, APPROX.BORING DEPTH�p <br /> BOLTED T FFIC BOX or 0 STOVE PIPE <br /> COMMENTS: � <br /> CONDUCTOR CASING PROPOSED,_(if YES,list specifications in comment section) <br /> �� -�� l� <br /> r41/ r7_ <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 in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed <br /> Title/Company (/NQS r-�,�Lh .e nAJ <br /> Print Name ) - �"�-, <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By '74/0(_ <br /> � <br /> Grout Inspection By I I'f z~ Date issued_ 1 4/0(_ 97 <br /> Date��Z ✓/'j AreaFinal Inspection By <br /> Destruction Inspection By Date <br /> Date <br /> COMMENTS/CONDITIONS; l)✓ t'..7 S <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# <br /> RECD BY DATE P ST# INVOICE <br /> -L a s _ q f p SR# 0C <br /> C-57 WC--WAIVER C-57 Letter of Authorization to sign permit_ ment doc <br /> EHD 24.02-001 <br /> 6/22/04 <br />