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03/02/2006 09 46 FAX 7077487717 (707)748-7717 Z002/003 <br /> 02/23/2006 08,21 2094' 33 EHD PAGE 02 <br /> r ` <br /> San Joaquin County <br /> Environmental Health ]department SI'TI= <br /> { 304 East Weber Avenue,3rd door,Stockton,CA 95202 MITIGATION <br /> (209)469-3449 Fax: (209)468-3433 Web: wr%Yw:co.san joaquin.cn.us/and UNIT IV <br /> NON-REFUNDABLA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applieabon is hereby M@de to San Josquin County for a permit 10 cornstruet and/or install the wodt dbscritMd. This eppIlCetion is made In Compliance with San <br /> Joaquln County Development Title,Chaptar 9-1179,8 2nd the Standarrda oft sen Joa On County Environmental health Department. <br /> WELL Location ' � t cst city p Parcel Jv <br /> y altliu'] <br /> PRQpE T4 <br /> Owner ffir <br /> C5 Addrt46sCaryC�t°l t7, 21p �3iSbneM <br /> C.87 ContraCto Atldrr99 ��77yy P Gky Zip Lica Phono# <br /> Consultant/Sub CnU r Addreae r )L rg7 <br /> X�4)rpe?aq_ �Gly CpOrglnatcte,XyTownshlp Ronne '� S2uloh, <br /> BE PERFORMED: <br /> EW WELL J BORING (CPT,GEOPROB1=,111 PROPUNCI 1,HANb AVGER,OTHER') 0 DESTRUCTION (cheese type below} <br /> n 0VER490RC_ p1 <br /> 0 SOIL BORING# <br /> WELL# Q Pt�E66URE GROUT <br /> WELL /n GROUT 5PECIFIGATIONIS <br /> COMMrNTS, <br /> TYPE <br /> p <br /> �WELL <br /> T CONSTAUG� FI TION <br /> T MONITORING p HOLLOW$TEM OIA.OF I3OREHOL r iI 0 MULYIPLE CASINGS 0 MULTI-LpVE4 WELL CASING DIA: <br /> p STEEL 0 Pvc Q OTHER <br /> EXHI <br /> TRACTION 0 AIR HAMMER/DRIVEN CASING TCKNESS — fYPE OK CASING: fl <br /> p VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL � TREMiE TYPE TO BE USED: p AUGERS 0 HOSE <br /> p AIR SPARGE/OZbNE [IPUSH POINT(GP or CPT)$ROUT SEAL PUMPED: I7 Yes p No ' ') <br /> (NOTE. MAXIMUM FREE-FALL DEPTH IS 3D <br /> Q BORING V HANO AUGER GROUT SPECIFICATIONS <br /> SOIL B <br /> SOIL B O OTHER, _ APPROX.BORING DEPTH U BOLTED TRA;FIG BOX or n STOVE PIPE <br /> /7DJ//7 CONDUCTOR CASING PROPO.$S0 (if YES,list specilluatl0nf M comment k�ctlCn) <br /> C - rcu <br /> GOMMENT8: <br /> NOTE: OFFSITIw BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that 1 helve prepared this application and that the work will he done In accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> �' � # YItlelGampany _ ° <br /> p'4.6Ign2d �� �7 <br /> • Date <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, E)13 ESS: <br /> WORK PLAN DATED: <br /> Applleatlon Accepted BY Dale Final Inspection Sy Date <br /> Grout Inspection Layh#'�� <br /> D9rtruc*in InapPCtion By <br /> Date <br /> COMMFNTS/CONDITION$% <br /> ACCOUNTING ONLY: AIC* F <br /> PE CODE$ FEE INFO AMOUNT REMITTED CH90K9 REC'P iBY t)ATE pERf/IIT/SERVICE RT-QUEST# INVOICE <br /> C-57— WG__-WAZVC:R._ C-57 Letter of Authorization to sign permits Encroachment doc` <br /> EHD 29-102•001 <br /> q/3oraooz <br />