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San Joaquin County <br /> Environmental Health DepartmentC L �I ✓i SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> �,- <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ad 3 1 2006 UNIT IV <br /> Well Permit Application ENVlRuNNIEEJNT HEA 17 <br /> PF <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDRMIT/SERVIrFS <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 /> ` /� Assessors <br /> WELL Location i p "-) y�• � k� -' Cross Street Af City�R Zip q5)-66 Parcel# 211�0 3 0 <br /> PROPERV/C'1-0 <br /> �1' p n /f /I <br /> Owner V t C for J 6,IS 10,12 �FM 5 Address f 6 6,9X �7 _City��0 � Zip 5Z3 1 Phone#��- T�S-SL00 <br /> C-57 Contractor_/Vr� Address City Zip Lic# Phone# <br /> Consultant/Sub Cntr LL 11?1 l�rr:,i///,c Address 227 CoN/s?elcE vCity 411 �! Lim 6 Phone# ?2-S-&$S-lo=,60 <br /> GIS Coordinates:X L'37(�3Q .-7 Y Zl (�o�, I Township Range Section <br /> WORK TO BE PERFORMED• <br /> 'NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH, HAND-AUGER,OTHER") 0 DESTRUCTION (choose type below) <br /> "QJSOIL BORING# 2� �-= OVER-BORE. DIAMETER <br /> DWELL# <br /> 11*Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE /I MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC Q OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL N TREMIE TYPE TO BE USED: a AUGERS D HOSE <br /> D AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING `\HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH_ BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> / CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: per Oarek r^4.,ge) /n l;,Q � earl <br /> If W&)"4M s4F <br /> r.•,i�-� w- + ro�� requ�rerhent�jgsed on �' lr rr,l� �{a�e •f.-cndArd. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> :ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> 1gned x `tel. �. �- Title/Company_ PR-0;I06-7 /tfUl.t4kG-'j- TIL.u.3 Gw-(, I.Jut�aS <br /> tint Name ED L'i I 'j AA- 7-j 4 7- 7 - 0( <br /> Date <br /> DEPARTMENT USE ONLY <br /> ITE MAP IN UNIT IV FILE,ADDRESS:__ a l p U W h+ 12gnA,41 f <br /> /ORK PLAN DATED:_ Zo o <br /> )plication Accepted By L� nntG1. Date Issued '61 1 I D C- Area Z <br /> rout Inspection By ilno�- „� Date Final Inspection By L� Cov� Date °1 )1 O(� <br /> ;struction Inspection By Date <br /> )MMENTS/CONDITIONS: <br /> \CCOUNTING ONLY: AID# FAC# <br /> E CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> D-loI oo �tlo( SR# 33 <br /> 57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc_ <br /> D 29-02-001 <br />