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_ 1 <br /> San Joaquin bountyW������D) <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95)6Y- 2 1 2006 <br /> ' (209)468-3449 Fax: (209)468-3433 Web: s MITIGATION <br /> www. <br /> `P jgENVfRdh41ENT HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Standar San Joaquin County Environmental Health Department. <br /> WELL Location /05' S /�.Gti< IQf �r .� p <br /> X. "Cross Street.s'7�"^`J Cit rly_" C•40"o la o f Assessors <br /> y if) Parcel# 93 2�0 C12 <br /> PROPE�RTYY _ <br /> Owner llraw: {� �'�r�/v Zddress /bSGO /-14.-1,�-OAX �NtG� <br /> 'J *��• '/ City C 0.�./ Zip�S Phone# Z.D 7�Z'y�s0 <br /> C-57 Contractor V W Ar *^'}'Address d abX T �} J �j <br /> 4sJ? /(v ity?�lC/..� zip7iS('fLio#C T RPhone* '�JG <br /> Consultant/Sub Cntrl�'����c "k✓� ddresd$ Ar <br /> As City w• Lic# Phone# <br /> GIS Coordinates:X Y Township Range.9 Section <br /> WORK TO BE PERFORMED: ��`�,,,,CCCC,,,, <br /> p NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) DESTRUCTION (choose ty a below) <br /> 9 SOIL BORING# <br /> a WELL# VER-BORE. DIAMETER ^ <br /> 0*Other @'PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> AA <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING I]HOLLOW STEM DIA.OF BOREHOLE-e 1]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: Z <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 1]STEEL APVC ()OTHER: <br /> j]VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS a HOSE <br /> o AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 1]Yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER:_0 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <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 /> Signed Title/Company 3-o ec.'sliJ? <br /> Print Name �'� ` '� "t ��-� �i r •� <br /> Date_ T/� Jlts 6 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDJESS: <br /> WORK PLAN DATED: <br /> ��� .� Cf j�J 2. Do(� <br /> Application Accepted By r7 r"� �` Date Issued ��/�:/o Area�T <br /> Grout Inspection By Date Final Inspection By —Date- <br /> Destruction <br /> ateDestruction Inspection By � . Date U <br /> COMMENTS/CONDITIONS: LVP / NFA/L <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3�az (JGF2 5 G� / j���i(, SR#() <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />