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02/05/2009 THU 15:03 FAX 20983433 SJC EHD 12001 <br /> ********************* <br /> *** FAX TX REPORT *** <br /> TRANSMISSION OE <br /> JOB 110. 2218 <br /> DESTINATION ADDRESS 92344700 <br /> PSWD/SUBADDRESS <br /> DESTINATION ID <br /> ST. TIME 02/05 15:02 <br /> USAGE T 00' 48 <br /> PGS. 2 <br /> RESULT OE <br /> glob # 2S'1057< �-(jb <br /> e U San Joaquin County <br /> r.•� �% Environmental Health Department SITE <br /> 600 E.Main Street,Stockton,CA 95202-3029 <br /> MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> c oR� Well Permit Application <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 9-1 Ij li.3 an the Standards of San Joaquin C my Environmental Health Department. [/ry <br /> i I y (•./ �_ p9 Assessor .© <br /> WELL Location < r Cross Streetit Zi Parcel# <br /> PROPE <br /> Owner N tl Addres t ll Zip Phl!on�ne# 66 b q <br /> C-57 Conlraclol r h Ire ddres /.V'. City ZIp�4rLij� haa 7' �!/10�( <br /> Consultant/Sub Cntr Addres i ity <br /> GIS Coordinates:X .Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE. DIAMETER <br /> �VpELZR—t RESSURE-GROITf'- <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I rl <br /> 0 MONITORING g't IOLLOW STEM DIA.OF BOREHOLE= 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 3 L rr TYPE OF CASING: a STEEL ,<PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL ter TREMIE TYPE TO BE USED: $,AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE O PUSH POINT(GP or CPT)GROUT SEAL PUMPED: O Yes O No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS dnnR <br /> .__._—.._.—__ ...._._. a..... . .__..__— ___ _. __ . . <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH g$ O BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> ( CONDUCTOR CASING PROPOSED (if YES,11.isstt specifications in comment section) <br /> COMMENTS:T tµ (' tiSMAIM v�._f �n�t�-� S(�P-W"" �l'�`.dhy� t— SW�� <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 OrdiiiancesoRules an tions,and all applicable California State Laws. <br /> Signed xj Title/Company 1 <br /> Print Name ✓ ale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: D <br />