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�tN #MENJ <br /> San Joaquin County RECEIVED <br /> Environmental Health DepartlmentMqY 0 5 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 <br /> MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:wcvlw.sjgov.oreAhdIOAOUIN COUNTY <br /> 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 Location I(nCU�VLDur4-C,,m4-erre;) cross street 4`t.c)�33 city -�vc�c� zIpC1`�_ Assessors <br /> PROPERTY Ciel rC `>` _�\SQ <br /> Owner _.SAddressk�Owvkrir+�i-©I City l'rCLC Zip AL' Phone# <br /> c-s7 Contractor IZZ5 -fU.4 ay \C Address_ 22c r� ECQSi Clty-\,L!�ip32-?bUcO Phone# L\���C� -2y 2'} <br /> ensu t1Sub CntrC.iFolrr C'Q�Vf,by�Lc, Address 1\01 �Nn`� . CityX10 Lic# r Phone# 200— Z IL9 <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> M ORK TO BE PERFORMED: <br /> ,6NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) 0 DESTRUCTION (choose type below) <br /> a SOIL BORING# D OVER-BORE. DIAMETER <br /> _5 -0,WELL# C7VJ-2 nt,�S�> O S- 2 0 PRESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS <br /> COMMENTS: Sec (o- la-05 s \tiCrk P�(ry (�y i C1 a �4C� \\-1-CCZS <br /> TYNE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS -'D5L C.'4FC�C4'E<'� CrCt`r1ti'k�Re�� <br /> J-Z,"ONITORING ) HOLLOWSTEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL n PVC a OTHER: <br /> ]]VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> >-1,FAIR SPARGE!(jZ�OqD 0 PUSH POINT(GP,,CPT)GROUT SEAL PUMPED: Byes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> Z a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: tl OTHER APPROX. BORING DEPTH a BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,Gst specifications in comment section) <br /> COMMENTS: SeE 0.\\-cAc��eFa \�' k PILc -,VQc� <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 /> Signedz �TNe/Company_ Da-t�ePrin me <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:A/ � <br /> Application Accepted By 11 14e�deed/ Date Issued--./,5-M41 `Q 4� Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 350 3 w y2 79• G / S 5,7C) CNri1 SR# 6 7 9 <br /> C-57._ WC—,-WAIVER— C-57 Letter of AUtharlZation to Sign permit—Encroachment doc— <br /> EHD 29-02-001 <br /> 6/22/04 <br />