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-an Joaquin County <br />Environmental Health Depart (�DD SITE <br />304 East Weber Avenue 3rd Floor. Stockton CA"J��� <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.orWey UNIT IV <br />�•. , � 2006 <br />Well Permit Application ENORI;-jjgilf N <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATf�YSS 1E.jq�TH <br />�j l�I E J <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 />„p <br />WELL Location 22-Zq 44a'}„ )- Cross Street Vu/, 5; ' Ci City Zip iS2LY:. Parcel# [ <br />PROPERTY I <br />Owner CUs.Address . 124! ►�%...J�._ , ` City Stoc f c• Zip Phone# r Zc <br />C-57 Contractor ��; �4<s ]�; 1 o ate. Address City tiar ". E Zip `iNSS; - Lic#C >C `IC1 Phone# �,?25i 313 5 BC)O <br />Consultant / Sub Cntr Address City Lic# 022'7 Phone# ('Zn�1iZl�o�-Ibo(� <br />GIS Coordinates: X <br />Y <br />Township <br />Range Section <br />CHECK # <br />WORK TO BE PERFORMED: <br />g-NFEW WELL / BORING (CPt, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER*) <br />p DESTRUCTION (choose type below) <br />3Sp3 <br />Q SOIL BORING # <br />3(08.0 <br />OVER -BORE. DIAMETER <br />5v <br />� <br />0 WELL # <br />10WNAL0ROUT <br />GROUT <br />Su <br />0 *Other <br />SPECIFICATIONS ONS <br />COMMENTS: <br />TYPE OF WELL <br />0 MONITORING <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE " 0 MULTIPLE <br />CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />0 EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br />V <br />0 VAPOR <br />0 MU ROTARY <br />DEPTH OF GROUT SEAL ( <br />TREMIE TYPE TO BE USED: {}AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE <br />USIH POINT (GP or PT),GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />OIL BORING <br />0 HAND AUGER <br />GROUT SPECIFICATIONS I'-xC J� <br />11 •.�f�F.. <br />0 OTHER: <br />0 OTHER <br />APPROX. BORING DEPTH 1[ x ,` <br />0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED <br />(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 />Countv Ordinances, Rules and Requlations, and all applicable California State Laws. <br />Signed <br />Title/Company Sr r 1 `;' •I o/rt <br />Date <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: 2224 Man+hey R64j - CA <br />WORK PLAN DATED`:/ Fe b rtA a f 4 17 <br />2Dt? <br />Application Accepted By V i Gi A r ;a L. Me La +n eel Date Issued u Ci U 5 �" �� Z L' G 6 _Area ) 4S- 9 <br />Grout Inspection By \' yt; �t�yi<<L . 1nC/°1e, f�?ZC, Date g C:' Final Inspection By V t APYIL� i L!6d- ate 2 21 - 674- <br />Destruction <br />'4Destruction Inspection By Date 1 <br />COMMENTS/CONDITIONS: Al yarlct r2,1Prtf o+ true e Pr boy-', ". Tn 12,Qf7Y6A--, die1w I Dn 4�Ppt hSq <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE PER E REQUEST # INVOICE <br />3Sp3 <br />2 9'D° <br />3(08.0 <br />R# 009772 <br />C-57_ WC --WAIVER _ C-57 Letter of Authorization to sign permi ncroachment do <br />_ c_ <br />EHD 29-02-001 <br />6/22/04 <br />