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u San Joaquin County - r <br /> Envir&wmental Health Department SITE <br /> m 304 East Weber Avenue, 3rd Floor,Stockton, CA 9520 r IGATION <br /> (209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/efid � NIT IV <br /> j��/��}fjWell Permit Application API; 1 0 2006 <br /> v R COIJDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSII. V)RoN1�Fl - ,t- ipI <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. A FS-rii �{n compliance with San <br /> .60 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Heat B t�ieG�Q <br /> �/ Assessors <br /> WELL Location`71f2D e. - Cross S�t�r�e'et1 V�)Y�O P. CityL n Zip , 2/s Parcel# r43(,343�'y � <br /> OwOe ERT' _/lr / /J Addressgjv0 C-Fretrwr+l t7f ..City-' (, 1" l _ Zip' ,S Phone ''U4 &3-527 ! oG <br /> CL CSYeI g� �1 "' q v z 5 2 1 'S�°� <br /> C-57 Contractor QqO J illinq Address i� (�73W rA�.Rid City �uC, -r,�Zip`iy5S3 Lic# honey 3 <br /> Consultant/Sub Cntr W jVaNl4&WCnVjLtVn&&Af2 Address&N gat') RJ City LCkL" Li,#68a ZZ-jt--Phone# ' oc( 11 �-100 LP <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> PEW WELL/BORING (CPT GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) a DESTRUCTION (choose type below) <br /> SOIL BORING# aOVER-BORE. DIAMETER <br /> a WELL# a PRESSURE GROUT <br /> O'Other _ GROUT SPECIFICATIONS <br /> COMMENTS: 2 CP'j (oca(lon° ' 1110gle �o(injS QQ�tt <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS - - <br /> 0 MONITORING a HOLLOW STEM DIA.OF BOREHOLES" 0 MULTIPLE CASINGS fl MULTI-LEVEL WELL CASING DIA:AA <br /> 1, a EXTRACTION - a AIR HAMMER/DRIVEN CASING THICKNESS NIA TYPE OF CASING: 0 STEEL a PVC a OTHER: Nf 't <br /> f 0 VAPOR ```D MUD ROTARY DEPTH OF GROUT SEAL'�'1 TREMIE TYPE TO BE USED: flAUGERS XHOSE <br /> i 0 AIR SPARGE/OZONE y6 PUSH POINT(GP or�jP GROUT SEAL PUMPED: Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> X,$OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS por{loM d :Yre 1 JTL <br /> I. a OTHER: . 0 OTHER APPROX. BORING DEPTH /Or)' 0 BOLTED TRAFFIC BOX or a STOVE PIPE . <br /> CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br /> COMMENTS: <br /> 1 <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 Or ances, Ru es and Regulations, and all applicable CalifornialState Laws. ( 1 q <br /> Signed x Title/Company Ul � 'S/ c LPIV rcrn 1tPti.("QY <br /> Print Na �4n -&hre06 Data i U, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: 4100 Frem o.ri f Street <br /> WORK PLAN DATED: N of e m b e r 12009' <br /> Application Accepted By Y i e-'I-e r f 0. L, M r= l .hr{-n ev Date Issued 4- 1001. Area 14 5? <br /> Grout Inspection By 'If'c,F-"'A IYIi ate- 4.2n-01_ Final Inspection By Vf l/4 l'&&Irblzr Date 21 106 <br /> Destruction Inspection By Date <br /> I COMMENTS/CONDITIONS: Adynxinp,meC P i <br /> ACCOUNTING ONLY: AID# 'F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3501 84 -it <br /> 3503 X2'14 368. DO SR# boy 6 339 <br /> i C-57_ WC=WAIVER__ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> i EHD 29-02-001 <br /> 6/22/04 <br />