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San Joaquin County <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 />WELL Location gl..03 E. H-vil Ve Cross Street Nifir City 81-vckfo n Zip 95_f, Parcel# I 0 i f '-iv 2-I <br />PROPERTY 4 rrktf/2, i r i N6 /-1 306 42 C (r IYJ <br />Adtess '"'P 1,7—t757-7 -r -ti' Ccry4t k Owner <br /> <br /> ichon zip 95 2.2i4 phonekrxeq-0 r . 414-1-4100 1' <br />4,111*-- We.s..,:t c(fL-E70- C-57 Contract° t:Te E d ItitiG41 t4 6-.? riillt-or e• Address /0 i (t E. Well a Av-c CItYArrkkfin't Zip 92-80iLic#V518. Phone# 411. 431 - 03'5 0 <br />Consultant! Sub CntrAtilkblreti 6.(DEAVirimMert1ai Address 8S3- Shaw Rd CityStPCkh, 11 Li c# ito 8-0 2'2,4 Phone# 207' 116,7- IDOG2 <br /> Range Section <br />Environmental Health Department T5)1 -If SITE <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 9520[211 rrs [c.„1, IGATION <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd UNIT IV APR 2 0 2006 <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE EIVIRONMENT HEALTH <br />, ERMIT/SERVICFS <br />GIS Coordinates: X , Y Township <br />WORK TO BE PERFORMED: <br />01 NEW WELL / BORING <br />0 BOIL BORING # <br />0 WELL # <br />1:1 *Other <br />COMMENTS: deSil, I wells bi <br />(CPT, GEOPROBE, HYDROPUNCH, HAND-AUGER, OTHER*) alDESTRUCTION (choose type below) <br />'MOVER-BORE. DIAMETER g a. <br />0 PRESSURE GROUT OA <br />GROUT SPECIFICATIONS IfiE 7--' <br />j oviy-ciri ii‘lli 41, tvf-tifi clef-ft, - behueeAl 410 ' - IVO ' bs ,3-. jbackalt 1-0 sv(fac.e LASh rDO-t- CD <br />TYPE OF WELL <br />fl MONITORING <br />0 EXTRACTION <br />VAPOR <br />0 AIR SPARGE/ OZONE <br />0 SOIL BORING <br />OTHER: OTHER <br />INSTALLATION TYPE <br />0 HOLLOW STEM <br />0 AIR HAMMER/DRIVEN <br />0 MUD ROTARY <br />fl PUSH POINT (GP or CPT) <br />0 HAND AUGER <br />COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 0 MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA: <br />CASING THICKNESS TYPE OF CASING: U STEEL fl PVC LI OTHER: <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: U AUGERS U HOSE <br />GROUT SEAL PUMPED: U Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or LI STOVE PIPE <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />(.11 <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby cert,jfy that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Orçtñances, Rules and Regulations, and all applicable California State Laws. <br />Signed x <br /> <br />.,041 <br /> <br />DEPARTMENT USE ONLY <br />Print Name Anna 'AehreviS <br />Title/Company c.St-afr (7 e0i is4- A &E <br />Date -41 /Z510te <br />••••.. <br />WORK PLAN DATED: 141 l I 14 <br /> SITE MAP IN UNIT IV FILE, ADDRESS <br />Application Accepted By L.-WA • <br />Grout Inspection By (A <br />Destruction Inspection By <br />5 /a fo <br />Date .61i6/06 Final Inspection By in ez,y) r 0 <br />Date <br />Date Issued Are <br />Date -5736/0 6 <br />COMMENTS! CONDITIONS: <br />ACCOUNTING ONLY: AID# F -S'rk---,ER60W(.?69 1 <br />PE CODES <br />3,2' <br />FEE INFO <br />\plio 1 <br />AMOUNT REMITTED CHECK # REC'D BY DATE VIDETtEDUEST # INVOICE <br />35o3 41,4c 4 '5 30\ ..3 ()f -my- sR# 4_16,3 .2 1 <br />C-57 <br /> <br />WC -WAIVER <br /> <br />C-57 Letter of Authorization to sign permit Encroachment doc <br /> <br />EHD 29-02-001 <br />6/22/04