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• r MENT <br /> o u N_c San Joaquin County R EKED <br /> 4 Environmental Health Department /NAY 0 5 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 9520yy J�OAouIN couNTMITIGATION <br /> (209)468-3449 Fax: (209) 468-3433 Web: www.sigov.org/ TQVIRONMENTAL <br /> HEALTH DEPARTMENT UNIT IV <br /> Well Permit Application c <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 S! 0 Z 3 34 <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 /> �-J, PC uew-,e.n-k ne�.}- -Fc^> 1 Assessors <br /> WELL Location \r��v;; Art`1Gm 12,rr�1�1 Cross Street "i`1Cily WsLi cam Zip SS�J7b Parcel# r��,Y�. <br /> PROPERTY _ <br /> Owner Y�\cad o-�Address 1010 (ctJ I`b&l'kxt At Cityc ro(',iC��n-IL'>1 Zip 220 Phone* C L2al4/ V—_50,15p <br /> C-57 Contractor 5c�1�C- Address 2 Z o t\ 1-CL- --A- Cily! )&oL ZIp�i0 Lid PhonedS3\L' lctn -2H2.q <br /> nsu t/Sub Cntr2g:i rS o\ -CPc-VW,c5 Address \\�r�t, - Cityj�Ud Phone*(z <br /> GIs Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> J NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) d DESTRUCTION (choose type below) <br /> a SOIL BORING# ROVER-BORE. DIAMETER <br /> �9VELL#BORING <br /> - k a PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: See "wheA v ,cxk 2 arm A,! A Sn \`\ C ,S ��k-Ckc-s <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS set xiAQC�W cl (.F.—' -�C PI Ck-,q-S <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_ a MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA:-- <br /> a EXTRACTION CRAACCTIONCC a AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL Q PVC 0 OTHER: <br /> a VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: BADGERS 0 HOSE <br /> g AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Ii Yes 8 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: R OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,tlst speGfiwfions in comment section) '1 <br /> COMMENTS: C)ePC0\\V, V` A Liu�- 7�y� C�t„�0 r� iP \Y DC 5 \r-'I 4V,�lVCaY\ -(�C- <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 /> Signed x `----� A� Tille/Company��'a <br /> Print Name � 'lG Date_J'`/7 S <br /> DEPARTMENT USE ONLY :Sj�fr r SA .ar <br /> SITE MAP IN UNIT IV FILE,ADDRESS: R 1.zy 73 0v t-53-3 7, -) <br /> WORK PLAN DATED: / 1 /� ((/� <br /> Application Accepted By GI // �G `' Date Issued �7r✓- C 1' "- ' Area <br /> Grout Inspection By Dale Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ?S� 3 u X179 °� U/8336 SR# pp 4/66$O <br /> C-57-, WC,--WAIVER- C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />