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San Joaquin County <br />nV"ronmental Health Department <br />, t Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(20 4�8-3449 Fax: (209) 468-3433 Web: w",w.sjgov.org/ehd <br />5 2006 Well Permit Application <br />lilECL"1a L iLLei7 UVlt v Lill/ <br />v <br />0 R I - <br />S�I <br />MITIGATION <br />UNIT IV <br />ENVIROIIVENT '4,F*TFFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED U <br />Application is herePfi)-* tib'f: Mf� Pb County for a permit to construct and/or install the work described. This application is made in compliance with San <br />Joaquin County Develo�ptment,Tritle, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br />YI L� I`' �f �� 4i-) 54- CAssessors <br />WELL Location l <br />L!, l i 1 ,�� � Cross Street I ity � u�,�1�r Ci- Zip Parcel# = ,3 - tpl � - O t <br />PROPERTY <br />Owner Ir`"2a Lrt L121 -rte Address 12.0 • 2>0.)t- I D2 -Z City i,Aa- 1 Zip�J�_Phona—(,? '2 239 - 14 14) <br />C-57 Contractor oYl111r Address PC, ! 3Lp City C Zip(lU�%f Lk IJC Phone# <br />ukant /Sub Cntr. C%.dilr � CQ �eCtl Address l IC t i _ City L1 kj � <;' Lic# Phone# l 269) _52Z - `i I I� <br />C�s <br />GIS Coordinates: X Y Township Range Section <br />WORK TO BE PERFORMED: <br />p NEW WELL ! BORING <br />0 SOIL BORIN # <br />0 WELL # <br />`Other <br />COMMENTS: <br />(CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) <br />\\ <br />0 DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />i_' t; - <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />MONITORING IOLLOW STEM DIA. OF BOREHOLE p MULTIPLE CASINGS 0 MULTI-LEVEL WELL. CASING DIA: _ <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS �� _ TYPE OF CASING. a STEEL PVC 0 OTHER: <br />All <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SFAI TREMIE TYPE TO BE U ED: 0 AUGERS 0 HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />0 SOIL BORINGAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH _ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS: CI, CSG C 5 U\ tom, 1t, \' \ l i_ f t 1 <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. d� <br />Signed xu�? _ cy Title/Company V � l ,ta. i <br />Print Name YCO-rr l�11 C t-� 1 C Date 5 �� <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: D ti. � <br />WORK PLAN DATED: 11---30 S <br />Application Accepted By Date Issued_ ��f0 �� & Area ,�6 <br />Grout Inspection By Date61?-710b_Final Inspection By Date__4`!/V b <br />Destruction Inspection By Da(e <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: <br />AID# FAC# <br />PE CODES FEE INFO <br />AMOUNT REMITTED <br />CHECK # <br />REC'D BY <br />DATE <br />PER INVOICE <br />So 3 Z <br />3 (o$ <br />0�r <br />R# <br />C-57 WC ✓ -WAIVER C-57 Letter of Authorization to sign permit, croochment.dee <br />END 29-02-001 — <br />6,/22/04 <br />n <br />C <br />