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- � • � AmJILE <br /> COPY <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202AUG 1 6 2006 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov. hNMENT HEALTH UNIT.IV /1i1`C <br /> Well Permit Application PERMIT/SERVIC <br /> NON-REFUNDABLE PERMIT EXPIRES 1 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 Counfv Development Title Chapter 9-1115 and the Standards of San Joaquin County Environmental Health Department. <br /> nn c� L 11 n� Assessor, /-� / <br /> WELL Locatio Y _. Cross Street City 90ele*p'n Zip 7r�o� .Parcel# ( '1r U 2-0 <br /> PR <br /> op <br /> a �ytn+.t,,� - <br /> Owner ..' / bl0 p �ff0 CIt*_k�J_YI Zip�Phone# <br /> C-67Contractor V"✓O'V,111QCTT Addressf-1112 +�rlpr Nn� //1��1va- City I-ewppMd r... Zip MS9Lic# Phone# <br /> Consultant/Sub Cntr UFR. oc. Address 1900 080ell S+- CityC LicdOD 92� Phone#LH j1 j S'-4500 <br /> GIS Coordinates:X V'416 Floor;Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> XNEW WELL/BORING (CPT OrnPROBE.HYDROPUNCH,HAND-AUGER,OTHER') g DESTRUCTION (choose type below) <br /> RS <br /> a WELL# RING#�- /FI /L'/2/ �OVER-BORE. DIAMETER <br /> O'Other f t 0 PRESSURE GROUT <br /> 11 GROUT SPECIFICATIONS <br /> COMMENTS: /1110 + CPT- <br /> TYPE <br /> PTTYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_2.0_" n MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 4o S TREMIE TYPE TO BE USED: 0 AUGERS gHOSE <br /> 0 AIR SPARGE/OZONE PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS_/K,[ata` Bzige&y — <br /> g OTHER: 0 OTHER APPROX.BORING DEPTH 30++6 0+ p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: MIP d- UT De <br /> 11 7Prkno�0A1?S <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby cerf1 that I have prep red this application and that the work will be done in accordance with San Joaquin <br /> CountyOrd' nces, Rules and Regulations, and all applicable California Striate Laws. / <br /> Signed x Title/Company Pf D I C.t`I & a.(oA1 C <br /> Print Name �4'�p+n `Tr l oto Date 106 <br /> DEPARTMENT USE ONLY <br /> 27— � 2.9. <br /> r 6 a <br /> SITE MAP IN UNIT IV FILE,ADD SS: G �� <br /> WORK PLAN DATED. <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date Y'j/-0P Final Inspection By Date <br /> Destruction Inspection By y Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 240 deo SR# <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to s gn permit_Encroa ent doc� <br /> EHD 29-02-001 !��7 <br /> 6/22/04 <br />