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• PAOI ENT <br /> ,6• ° ' \ San Joaquin County RECEIVED <br /> Environmental Health Department <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202MAY 0 5 2006 SITE <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.or&(AhdloAOuIN COUNTY <br /> MIT1GATION <br /> •4C�p Q.�P��/ ENVIRONMENTAL - UNIT IV <br /> Well Permit Application HEALTH DEPARTMENT <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 Standards of San Joaquin County Environmental Health Department, <br /> WELL LocationIIoCOWDur� mVP rr CEJAssessors <br /> Cross street f1u,�4 �',3 city Tvt�c,`.e Zip°r5 Parcel# 27F�- �cY-�-� <br /> PROPERTY C-)W <br /> OwnerZfrt < Yom, Address ttt'cl k=7uv}-�,.� City 1_2\.r ZipcS-' l Phone# Q %-5.5 <br /> C-57 Gontractor_ �i.4 -i\C Adtlress_22-D N E4!.S- ` � City I��IP�.l�lo Uc# Phone# �\�Z LQ <br /> onsu t I Sub Cntr_C�Ep1r`Gr� �- f�k S Address_11(c1 2!L'-- City <10 Lia# Phone#�ZCq,> 4.11 of <br /> GIS Coordinates:X.,Y ,Township _ Range Section <br /> )NORK TO BE PERFORMED: <br /> ,6NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (choose type below) <br /> U SOIL BORING# <br /> $,WELL# �7MI-Z ()S- ( !�5- Z 0 OVERBORE. DIAMETER <br /> 0 <br /> U`Other � PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: Sea C�Atao�-�-fl lc a P\c�� �o l0 1� C5 v \tiCrK PW"n RAr9 nvt,rn �4c� U- 7—Lz5 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS `S- e <br /> d-Z,"ONITORING OHOLLOW STEM DIA.OF BOREHOLE` 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: d STEEL U PVC D OTHER: <br /> p VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ll AUGERS a HOSE <br /> Z�RAIR SPARGE1 ZO a PUSH POINT(GP or CPT)GROUT SELL PUMPED: U Yes a No (NOTE-MAXIMUM FREE-FALL DEPTH IS 30') <br /> d SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> la OTHER: n OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> COMMENTS: Sec (kti\0-0>EA <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) g <br /> �9��1(_ C��C�VI c�IA�2(A �r A`� C' ,T�cw-V V0 4- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 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. 1 <br /> Signed xTNefCompanyy <br /> Prinat�maDate S` <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:A/ � <br /> Application Accepted By.. 1// 14en�2�J o� Date Issued lS M r p <br /> Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspecton By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> isoo° s yz79- .: G/ d`'3X� Cviil sR# 679 <br /> C-57,-_ WC -WAIVER,____ C-57 Letter of Authorization to sign permit_Encroachment doe___ <br /> EHD 29-02-001 <br /> 6/22/04 <br />