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San Joaquin County <br />Environmental Health Departt-rent �'�'�fiD SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, C`A 95202- MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgpv,.org/ehd UNIT IV <br />�Fa r I I Well Permit ApplicatiOnFNV1R0,1,v,,0gT HEALTH <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D, 96ifgbERVICES <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 <br />WELL Location 3'15 Lv, Niazejio- A Cross Street S- Lincc),n q. City Zip R52_01 Parcel# 141'712.008 <br />PROPERTY .n�1 <br />Owner S;erro, L%t I/44JersAddress Pp. I? -,K C,7_1(, City !icc�-�� Zip 95-2cL� Phone#_�Io�1�gK3 <br />C <br />"16'&C-57 Contractor / aS�w�� (i;� Address 3032 �rHec c City �or�cvc. Zip S IIZ Lic#'11'75I0 Phone# �41��(e38 II�R <br />Consultant/ Sub Cntr .4 L.Address 93-1 SI'Law 12r� City S e . Lic# Le,2n 22_ -f Phone# <br />GIS Coordinates: X , Y , Township Range Sectio <br />WORK TO BE PERFORMED: <br />0 NEW WELL / BORING <br />0 SOIL BORING #_ <br />0 WELL # <br />0 'Other <br />COMMENTS <br />(CPT, GEOPROBE, HYDRA9000 4 , IER*) <br />APR 1 7 2006 <br />U16ESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />g11RESSURE GROUT <br />GROUT SPECIFICATIONS T <br />TYPE OF WELL INSTALLATION TYPE CONST9U'''IRJN`9PECIP1CATiONS <br />MONITORING 0 HOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Scj,. qO TYPE OF CASING: 0 STEEL 9-15VC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL i9,` TREMIE TYPE TO BE USED: 0 AUGERS KHOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: XYes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS"J-11T L �I &-)e_�ev_k <br />0 OTHER:_0 OTHER APPROX. BORING DEPTH tjD' "BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED nn (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 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 x. <br />Print N <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: 6-1",4 `/ /l7 1 <br />Zn <br />Title/Company +,+f (Yeo�ogish �� �F <br />Date 6C - <br />DEPARTMENT USE ONLY <br />t�L/D/ ' n <br />Application Accepted By Date Issued 7;/�6 Area / ,77 <br />Grout Inspection By <br />Destruction Inspection By 414A <br />COMMENTS / CONDITIONS:%tLJ <br />Date <br />nal Inspection By <br />-Des <br />ACCOUNTING ONLY: <br />AID# <br />F <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE E # <br />INVOICE <br />3 .oZ <br />�c^.cc <br />o.cc <br />81 <br />�K <br />y�r�' p SR# CCW' <br />3S.03 <br />oc <br />7-79-cc,-�� <br />9 <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permitdoc <br />EHD 29-02-001 <br />6/22/04 <br />