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San Joaquin County �O'" ,Y <br /> Environmental Health Department 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 2006 JUL —5 Mk o <br /> Well Permit Application SAN J0A7. „< t. <br /> ' NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN V I R 0 N M E 1 T A L <br /> HEALTH CEPARTMENT <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 Tillie,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> V,yr <br /> ' Owner 111 <br /> ld <br /> � <br /> m { _ o <br /> Assessors <br /> WELL Locao "PiVCey AN Cross Street Cf CekA 1?8 Clty ^`4k�P zip 703t; Panel# 9 <br /> (13-310- O <br /> I <br /> PROPERTY-7, Z " as S F ear{ d jur% on <br /> LrZ3GI& Address S7ewar� Rd city Lc, rzp_gU30Phona# <br /> C37 Contractor Address pD•n7rd 416 CityZl lln Zia4�9o4 _174- y/00_Phon <br /> Consultant/Sub Cntr� °u� �� AddressMo N.T'rQCy $llklclty�(L1Cr-c•1 Lic# <br /> GIS Coordinates:X Y ,Township flange Section— <br /> WORK TO NE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) fiDESTRUCTION (moose type below) <br /> 0 SOIL BORING# I OVER-BORE. DIAMETER Q A <br /> u WELL# x 0 PRESSURE GROUT �q3 <br /> a'Other I I / �` GROUT SPECIFICATIONS <br /> COMMENTS: b b/Yh211�: Ol nm5 4 iAOt M11 � CYC pr -(: l}V-G �.•2,13Q <br /> ' TYPE OF WELL INSTALLATION TYPE CONSTRUCTION 8P IONS <br /> TAONITORING I10LLOW STEM DIA OF BOREHOLE n 0 MULTIPLE CASINGS 0 MULTI-LEVEL L CASING DIA: C 1 ACL <br /> p EXTRACTION u AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING O STEEL ED0 OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TRE VI E TYPE TO BE USED: ]AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROIIT SEAL PUMPED: 0 Yea S No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ' a SOIL BORING n HAND AUGER GROUT SPECIFICATION 5121`tF o — cam✓ D-Sr Lys <br /> o OTHER:_a OTHER APPROX,BORING DEPTH_0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> SS I CONDUCTOR B�AASING PROPOSED if YES,list apedncations In comment section) <br /> COMMENTS: cU1TE yIG� �Ybwr� �a GOn'4nMi%-�^P.l <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify tt 11 Mv repared this application and that the work will be done In accordance with San Joaquin <br /> County 01It and egulatlons,and all applicable California State Laws.Laa�ws. L C <br /> ' Slpnetlx Title/Company. .SfbTT `TLc(OQ73'! /L� n9C6.=AC, <br /> Print Name ,QIGF+49 GANDo LPO Date .JIAIn Jr JqDb <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: / 41 <br /> WORK PLAN DATED: -$•O <br /> ' Application Accepted By Dela Issued Area O <br /> Grout Inspection By cd <br /> Date Flnel lnsPeon 6y7-'1-]�t�[�j <br /> Destruction Inspection By Date 7-17-0 b <br /> COMMENTS/CONDITIONS: <br /> ' ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �Y WD 660 ?-- 7.5.6 s 3o 2-- <br /> C-5T_/ <br /> C-57_ WC WAIVER_ C-57 Letter of Authorization to sign permi _Encroachment doc <br /> ' EHD 29-02-001 <br /> 6/22104 2 Q- <br />