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03/09/2006 14:27 2094683433 EHD PAGE 02 <br />San Joaquin County <br />Environmental Health Department SITE <br />�_ 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 9 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 />�8 L (1c;1� SI LJ�(� e�^ `%.Z 37 Parcel# Assessor 0 RO �-2 <br />WELL Location /y000 E f/i-y Cross Street City, tigP <br />OwnePERTYTime, A( Cu. Address 1'737 0- (vrVl.�,oaQo1 C� SPr� Azip 419 / Phone# L0L--2b'57-2g00 <br />C-57Contractor(,jnQ br'11"Acl Addressc�yJ F(o�z�`Q� �' ^e7- <br />CltyZp`i`rsryLiC#�3s1�7Phone# .�5- 13'7-8'v0 <br />ConsukaatcSubCntr d0— /453.2c--'6 Address (30 L'=-414-1 5, _City <br />GIS. Coordinates' X_ . Y , Township Range Section— <br />WORK <br />ection <br />WORK_ -TO 8E PERFORMEI7'- <br />p NEW WELL/ BORING .(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) DESTRUCTION .(Choose. type below) <br />a SOIL BORING. # C OVER -PORE.. DIAMETER <br />0 WELL # %ZPRESSURE GROUT L <br />0 *Other, GROUT SPECIFICATIONS ACA+ CP�P-iT <br />COMMENTS: <br />TYPE OF WELL INSTALLAiLON TYPE CONSTRUCTION $PFCIFICATIONS <br />MONITORING iOLLOW STEM g r DIA. OF BOREHOLE 0 MULTIPLE CASINGS a MULTI -LEVE.. WELL CASING DIA:.-�. <br />0 EXTRACTION /U,.,IR HAMMERIDRIVEN CASING, THICKNESS TYPE OF:CASING: U STEEL U PVC n OTHER: <br />�/APOR a. MUD. ROTARY DEPTH. OF GROUT SEAL TREMIE.TYPE TO. BE USED; d. AUGERS 0 HOSE <br />Q AIR SPARGE! OZONE n PUSH POINT (GP. or CPT)GROUT SEAL PUMPED;. 0 Yes -:0 No (NOTE:. MAXIMUM FREE -FALL DEPTH IS 30'.) <br />11 SOIL BORING 0 HAND AUGER GROUT. SPECIFICATIONS <br />0 OTHER; 1] OTHER APPROX, BORING. DEPTH 0 BOLTED. TRAFFIC BOX or 0 STOVEPIPE <br />CONDUCTOR CASING PROPOSED (f 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 />hereby. certify that I have, prepared this application and that the work will. be done In. accordance.with San Joaquin <br />County Ordinangps, Rules and Regulations, and all applicable. California State Laws. <br />Signed <br />Print N <br />/Ua /'/14, /tic, <br />SITE MAP. IN, UNIT IV FILE, ADDRESS: <br />Title/Companyy��v/!AL1t�u cLi.^.cis+ L . -� /11Cjlx,.:� <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: <br />Application Accepted. By, t' + —' Date Issued S- S ` Area <br />Grout Inspection. SV DatFilial Inspection By. Date <br />Dole- <br />Destruction. InspectIon <br />COMMENTS I CONDI <br />ACCOUNTING ONLY; I AID# <br />Date -1G' 2Z 16 <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY tDATE PERMIT! <br />3a��z Lo- Cin S ( �.f $R# <br />C-57 WC --WAIVER— C-57 Letter of Authorization to sign permit_ Encr( <br />F,HD 29-02-001 <br />6!42/04 <br />EST# I INVOICE <br />1q�v 13 <br />