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• POMENT <br /> a San Joaquin County RECEIVED <br /> � n x Environmental Health Department MAY 0 5 2006 SITE <br /> "R ft <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:W Ww.ajgoV.or§(Ahd OAQUIN COUNTY <br /> ENVIRONMENTAL UNIT IV <br /> �Fo <br /> Well Permit Application HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT EXPIRES t 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. IloCb W Dur4-Ckr�rrru Cross Street City 7v2Assessors <br /> —ZipParcelp <br /> PROPERTY C-f-o�. <br /> Owner -CF_yrLa1lA,;rte. Address vt-% v-h0.m city--k v!L�Zip�lEPhone# <br /> C-67 Contractor 90_�_4 Address. 27-D V� \'bl <br /> onau tISubCntrC:lf0\* Ca\ 'rhn&CS Address 1\0I 'Nh` Cityuta - Peat CzeoL) ,2z.-yh)ol <br /> GIS Coordinates:X_ ,Y ,Township Range Section <br /> WORK TO BE PERFORMED; <br /> ANEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER? Q DESTRUCTION (choose type below) <br /> 1]SOIL BORING# DOVER-BORE. DIAMETER <br /> ,WELL# \AI-Zice.-�._5 p S- 2 0 PRESSURE GROUT <br /> p•OtherI GROUT SPECIFICATIONS <br /> COMMENTS -cSCc. CLkVCAO\-YFr1 LCk-_�-1 r\C,\a .rc-' <br /> TYPE OF WELL INSTALLATION TYPE _CONSTRUCTION SPECIFICATIONS -SCe. Lett o cL -)oA Lo�- V<-P�0.e�5 <br /> J-Z,"ONITORING HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION p AIR HAMMERIDWEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC II OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> >--\, ,AIR SPARGEIZO 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 301) <br /> ' z 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER: R OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (H YES,fist specifications In comment section) c <br /> COMMENTS: `DP-q- 0.\fcsc ales ` `v�(lC- 1P�tv� (X'�Q C�. 1,1 m-�T V.l i7+'k V\0.r\ f�-js iv�c,.1.1-ti'(1 C 1i'OJ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 46 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__ - Tifie/Company a <br /> Pnn ams _ Date f <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 15 M'Z O Area <br /> Grout Inspection By Date Final Inspection By —Date— <br /> Destruction <br /> ateDestruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> iso 3 w 4K 79,00 <br /> �z79- 6 / �33� Cvril sit# 004 679 <br /> C-57_ WC_-WAIVER____ C-57 Letter of Authorization to sign permit_Encroachment clot— <br /> EHD 29-02-001 <br /> 6!22!04 <br />