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umuiNAL <br />SITE <br />MITIGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV <br />Well Permit Application 2006 MAR -2 AM II: 53 <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1§,§Uf1),.; .; , f <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work de1çt6 11,1;9'46 ade in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Envi6ti thl1-16)-At berbirtri-fete <br />WELL Location 0.39 L. '-fl jC1 I-4t..fy Cross Street Mor SE <br /> <br />Assessors <br />City LO I Zip c1S-2 4.° Parcel# 4,5-ct Z-1., 01 0 <br /> <br />PROPERTy <br />Owner Ti -"I'COC.Hck r-1(.., Address 113 1 t, tJoti1-( 99 J-iwi City (_, ob j Zip9'57.-4 0 Phone# "Z-D`i 3 l Loa 0 <br />C-57 Contractor (t)Cr6D(.4A-R-1. be,E.IANddress 315,2, g3 L City t-I, V i5Nr Zip44571 Lic# 7100-79 Phone# -) 67 7".i'l i1:311-0 <br />Consultant / Sub Cntr DN,...1,--1 CA-LOL-Ii.: LL- Address /0Si-0 4,-t ITE- //DO< Cityfrr-Ho - Lic# Phone# 1 I Is 'IL( 4-1 0 12 ..... <br />GIS Coordinates: X 3'.11 53°10,7-L. y , Township Range Section <br /> <br />UI <br /> <br />WORK TO BE PERFORMED: <br />NEW WELL / BORING (CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) <br />SOIL BORING # <br />Et WELL # - 44.0 <br />a *Other <br />0 DESTRUCTION (choose type below) <br />fl OVER-BORE. DIAMETER <br />fl PRESSURE GROUT <br />GROUT SPECIFICATIONS <br /> <br />COMMENTS: <br /> <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />O MONITORING ()HOLLOW STEM DIA. OF BOREHOLE /3 .--kff] MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br />O EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: ...P <br />qAAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL Z-0 1 TREMIE TYPE TO BE USED: 0 AUGERS a HOSE .....0 <br />IR 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 BORING 0 HAND AUGER GROUT SPECIFICATIONS <br />0 OTHER: 0 OTHER APPROX. BORING DEPTH 60 g BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED (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 />Presietanf <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # -..._ REC'D BY DATE P : - - - - - 0 UE T# INVOICE <br />--1.../5c$ <br />356 z 279, 36Vr 335 if aX-- -/I) SR# 00q6 el <br />C-57 WC VI-WAIVER C-57 Letter of Author'zation to sign permitiil Encroachment doc. <br /> <br />Signed x E OrertiVedVri—Title/Company <br />Corv)in,9 LA) tra-d uJarcA <br />DEPARTMENT USE ONLY <br />11.3q6 AL icZei( 17?, 496b; <br />Date L. <br />COMMENTS / CONDITIONS: <br />Date <br />Date <br /> <br /> Date Issued <br />Final Inspection B <br /> <br />El-ID 29-02-001 <br />6/22/04