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Slin Joaquin County � � vL +JI <br /> En' viroi ental Health Department J&-J2 5 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 9 MITIGATION <br /> 209)468-3449 Fax: (209) 468-3433 Web: www.sjgay.or N00VT HEALTH UNIT IV <br /> � !T/SERVICES <br /> [rad' 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 andlor 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 /> n� <br /> Assessors <br /> WELL Location- iG5DO Y\lr, 6))ffd•, la,r� 1T).Cross Street &:4&:4; 0,)_ City Zip q94C G Parcel# 199 Olt 15- 11 <br /> PROPERTY r <br /> Owner 1014in 5�.� rr,,L off. Address 2936 V&'.'' jor City. 1 `le'e"ts Zip 53g1)Phone# 4=2) 9�f 3� 2©7-j <br /> C-57 Contractor 1ni%LeJf 1/� ddress (v / ;, _City sur ti Zipq55bXLic#_&A 'IPhone# LD 0Ya <br /> j Consultant/Sub Cntr Aci—L Address S1:1 Sew. . City Sc�.oL Lic#690ZZ'T Phone#-6��°7— i�6C, <br /> i GIS Coordinates:X 'Y' Township Range Section <br /> WORK TO BE PERFORMED: <br /> Ul EW WELL 1 BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> a SOIL.BORING# 0 OVER-BORE. DIAMETER <br /> 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> R-96NITORING +�IOLLOW STEM DIA.OF BOREHOLES 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ZR <br /> a EXTRACTION a AIR HAMMERIDR 'IVEN CASING THICKNESS Stt. c TYPE OF CASING: a STEEL �C Q OTHER:.VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL{(fl' Li TREMIE TYPE TO BE USED: d AUGERS 0T-0SE <br /> a AIR SPARGE/OZONE [I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Beres ©No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30`) <br /> 0 SOIL BORING o HAND AUGER GROUT SPECIFICATIONS -7-Ube- S/JE: P djA,� <br /> 0 OTHER: Q OTHER APPROX. BORING DEPTH y_ 5-5 F 0-96L-TED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (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 /> f County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company— <br /> Print acne ' Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE;ADDRESS: <br />'i WORK PLAN DATED: <br /> f Application Accepted By NAekaH Date Issued ©el IG/Q Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> iso ` rz z 00-1 SR# 004 7197 if <br /> C-57 WCC WAIVER C-57 fetter of Authorization to sign permit Encroachment doc <br /> r EHD 29.02-001 <br /> 6/22/04 <br />