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l e k is made in compliance with San <br />iC6k,' -a t. <br />Assessors <br />Parcel# <br />Title/Company Signed x LICVle) <br />Print Name <br />Date <br />ORIGINAL <br />SITE <br />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 2006 AUG I 4 PM 12: 22 <br />San Joaquin County <br />Environmental Health Department <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAsTA 1§SIJEp <br />WELL Location 2,66 5 ev . ote ex.....,4 Cross Street r-iff ,KI,',‘ h.: City <br />il -./ k i 4 •,e <br />Address /8/0 /4/12- i 'ion City :.---Siuk.Kr r,v1 Zip 95.1.:). 1 Phone# c1(1' ) ti(./t <br />Address 956 Howe_ 80 Jo city194rhda z9 5-5 .1 Lic# 65. (' Y LI P7One# •)2.5...) 113 SY c, 1.) <br />Address a S - 7 5 i*/ 4 A ° City Sr(A (10,1Lic# CO C.) .1 I 7 Phone#0.5') )13 7--/ <br />GIS Coordinates: X <br /> <br /> Township Range Section <br /> <br />WORK TO BE PERFORMED: <br />1NEW WELL / BORING EPT>GEOPROBE, HYDROPyNCH, HAND-AUGER, OTHER*) r OIL BORING # CP -14 (ID r-i c_er <br />WELL # r- <br />1:1 *Other <br />COMMENTS: SEA_ PIAN riD #pr <br />CONSTRUCTION SPECIFICATIONS A)/ <br />DIA. OF BOREHOLE 141/q ' 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: frl <br />CASING THICKNESS 1'1.'r TYPE OF CASING: 0 STEEL 1:1 PVC 0 OTHER: ifq--3 <br />U VAPOR 1:1 MUD ROTARY DEPTH OF GROUT SEAL ial.-. 1. TREMIE TYPE TO BE USED: 1:1 AUGERS a HOSE <br />0 AIR SPARGE/ OZONEUSH POINT (GP or GROUT SEAL PUMPED: tYes p No (NOTE: MAXIMUM F_RE,AzFALL DEPTH IS 30') <br />‘31q0IL BORING 0 HAND AUGER GROUT SPECIFICATIONS PC r rla.,..0 izix ,4i <br />fl OTHER: 1:1 OTHER APPROX. BORING DEPTH / CI q ' BOLTED TRAFFIC BOX or [I STOVE PIPE <br />CONDUCTOR CASING PROPOSED f`J/41- (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 0 • ances, Rul nd Regiilations, and all applicable California State Laws. <br />Pa Q 7 <br />DEPARTMENT USE ONLY <br />SITE MAP IN UNIT IV FILE, ADDRESS: ..01/ 6 elt,/,- e-oe- <br />WORK PLAN DATED: <br /> /tt — <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the worls cl,e5drfid.• v,nrt. a <br />Joaquin County De-1,--..nt TitIP rhant,:r Q..111 g "'"I the Standards of )an Joaquin County VEo i4irkaielfitafiWa <br />I\r; Zip 2/03 W, <br />C-57 Contractor 6 t 0!,11),' <br />Consultant / Sub Cntr n a • ri <br />2.3)S7 PROPERTY <br />Owner 3 , ( fv, Pv 3/1 (- / w r ic <br />0 DESTRUCTION (choose type below) <br />O OVER-BORE. DIAMETER <br />0 PRESSURE GROUT <br />GROUT SPECIFICATIONS <br />r / "---" <br />TYPE OF WELL <br />MONITORING <br />fl EXTRACTION <br />INSTALLATION TYPE <br />O HOLLOW STEM <br />O AIR HAMMER/DRIVEN <br />Fr <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />Date Issued <br /> Date Final Inspection By <br />Date <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE PER - • INVOICE <br />3:19^2-,1 ' 2.V.5 3•41 21 /4/-01/ :i:&4gA S R# COW.F61 <br />C-57 V WC WAIVER C-57 Letter of Authorization to sign permit <br />& )--V 0 a EHD 29-02-001 <br />6/22/04 <br />