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03/09/2006 14:27 2094683433 EHD PAGE 02 <br />San Joaquin County <br />Environmental Health Department SITE <br />ta 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 />NOWREFUNDABLE 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 St dards of San Joaquin County Environmental Health Department. <br />C { n Assessors <br />WELL Location, f tc q (A5 Cross treet lP�( J+- City CGc Zip %S 3'7 Paroel# �'�� J <br />PROPERTY _ <br />Owner C •4L /A Address City Zip Phane# <br />' ?� cl z "46S 31.100`l�C5'�. =-Phone# ))S-3(3 -�5 Lav <br />C-57 ContraCto� JLc3�r ,�, ll�n , Address �I ty pts— - <br />Consultant[SuhCntr �s' =j Address t 3� L^°f4,,� S Ciry M�� Lic# . Phone# �{ZS-77�-C)lo7 <br />CIS Coordinates' X , Y Township Range Section <br />WORK TQ 13E PERFORMED'_ <br />n NEW WELL. / BORING . (CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) DESTRUCTION . (choose type below) <br />OVER-60RE.. DIAMETER <br />' <br />n SOIL BORING. # <br />RESSURE GROUT <br />WELL # <br />p "Other GROUT SPECIFICATIONS <br />COMMENTS: <br />f - <br />�C. <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />-� <br />MONITORING IOLLOW STEM DIA. OF BOREHOLE d MULTIPLE CASINGS O MULTI-LEVEL. WELL CASING DIA' <br />/ n EXTRACTION p. AIR HAMMER(DRIVEN CASING. THICKNESS YPE OP CASING: [j STEEL Q PVC OTHER: <br />a VAPOR o MUD. ROTARY DEPTH OF. GROUT SEAL TREMIE TYPE TO BE USED; n AUGERS 0 HOSE <br />n AIR. SPARGEL OZONE n PUSH POINT (GP. or CPT)GROUT SEAL PUMPED: a Yes . 'n No (NOTE:. MAXIMUM FREE -FALL DEPTH 1S 301.) <br />d. SOIL BORING n HAND AUGER GROUT. SPECIFICATIONS <br />OTHER;_n OTHER APPROK, BORING DEPTH 0 BOLTED TRAFFIC BOX or n STOVE. PIPE <br />CONDUCTOR CASING PROPOSED Cf 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 Ordinances, Rules and Regulations, and all applicable California State Laws. <br />-- <br />Signed x —Tltle/CompanyiZv/��nr� <br />Print Name /!/�i G o!� v Date -7�D� <br />DEPARTMENT USE ONLY <br />SITE MAP. IN, UNIT IV FILE, ADDRESS: <br />WORK PLAN. DATED: <br />Application Accepted By "�^^^�`� Date Issued 1 ��� L� b Area <br />Grout Inspection. By Date 41 Final Inspection By. Date <br />Destruction Inspectlon By Date A 2 91 V b, <br />COMMENTS I CONDITIONS: 3 �+j <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PE R INVOICE <br />11 14� % <br />C-57_ WC _ -WAIVER_ C-57 Leiter of Authorization to sign permit_ Encroac <br />6/22/ � 2h -0Z-001 ! <br />� C <br />6/2210a �' - - 41 r '� - � ��� � /_ <br />i <br />