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FILE COPY <br /> r, <br /> San Joaquin County <br /> Environmental Health Departm # -���/ �� SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 -1VIITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.orgtbd 2 2006 <br /> UNIT IV <br /> Well Permit Application lication ' <br /> !liar? <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE 101MVIM.SLEMACES <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 /> 'N„00y <br /> WELL Location LCt 5`6R M f 1G.n le A� Cross Street 1s;e)i;4��d A� City M cr4-e� Zip Parcel#� "Y/`� <br /> PROPERTY Z ('�� r <br /> Owner 4-rw {�4Y.ms �",cAddress_ ib C) LL7c�`l 3"" City5�5-5,S-e Zip 4sr+ Phone# r-/ors c{Z"+eta <br /> C-57 Contractor c«;t'1 Ase&WE curieAddressrao-r crus cme"neflsr mc,, A City S+wJosa Zipgs+zs Lic#*Vf5 n 3 Phone# -44.6111 9 ey-f—i <br /> Consultant I Sub CntrLi coir R mA Address nal L,nGE &xrr-A City swJose Lic# N-VS 44"> Phone# 4#6 9-Iq D rc-e5( <br /> GIS Coordinates:X ,Y Township Range Section <br /> 2 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> -,J�SOiL BORING# Z 4 , , y a OVER-BORE. DIAMETER 3 <br /> a WELL# 4 / F 7 0 PRESSURE GROUT <br /> 0*Other r GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CON RUCTIO S CIFIC NS <br /> a MONITORING XHOLLOW STEM 1 . BOREH E MUL PLE CASINGS a MULTI-LEVEL WELL CASING DIA: <br /> EXTRACTION a AIR HAMMERIDRIVE C 5t G THICKN TYPE OF CASING: p STEEi p PVC (]OTHER: <br /> a VAPOR a MUD ROTARY D PT OF G UT SE TREMIE TYPE TO BE USED: O AUGERS 0 HOSE <br /> D AIR SPARGE!OZONE a PUSH POINT(G o PT)GROUT AL PUIVP : a Yes No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING a HAND AUGER GR O SPEC[ A NS I i <br /> p OTHER: a OTHER PROX:BOG H 50' '- 0 BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CA G PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: 6 fie. (C" - u-T --a„ti n frs.oetw-4--N r. '-aro`ci <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cern thatI have p e red this application and that the work will be done in accordance with San Joaquin <br /> County Ord' n�c�e�s, Rule n Reg lations, and all applicable California State Laws. / n <br /> Signed x """”` Title/Company P­-�+�� (��r <br /> Print Name .k ' e 'Date <br /> DEPARTMENT USE ONLYS� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued r Area d <br /> Grout Inspection By Date Final Inspection By IK <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# - a FAC#1 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> C-57 V WC -WAIVER C-57 Letter of Authorization to Sign permits Encroachment doc <br /> HHD 29.02.001 <br /> i 6/12104 F i y <br />