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P0.0�^r • RAM V E fl 14PRt <br /> o San Joaquin C6unty <br /> �:-:.. .o <br /> Environmental Health Department <br /> JAN 1 1 2006 SITE <br /> 7 ` 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.dL�IfWMENT NEALITI <br /> PERPAIT/SERVICES UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED aciaNwith <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 San <br /> Joaquin County Development Title,Chapter 9-1115.3�and <br /> y�the <br /> --Standards of San Joaquin County Environmental Health Department.tssesso /gyp (� 77 <br /> WELL Location���� W GT PCross Street�City .lt0/ nr, Zip Parcel#rs✓/ •//D•T3 <br /> PROPERTY // 1 <br /> Owner �tin(ol., w ,n rr- Address "BAR City-!9 Zip Phone# 'I�i• Rl-0 O <br /> C-57 Contractor&K�5inn�rr0/'a,T Address�hSl Sw qq ,� City Zip Li 10 Phone#j& -�5�5— <br /> Consultant/Sub Cntr f �- Address�Que /ts doll �ci.-I" City (yj-(�Lic# Phone# 3 Sd- <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING ICP�T,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) a DESTRUCTION (choose type below) <br /> 4 .r <br /> SOIL BORING#nTl- <br /> " Kft�-j&fl• P?794' 119-)r/)2P-$ r7L.P-Ar ftijf_l11, p OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> a•Other rII FL l3, MTP I2 GROUT SPECIFICATIONS <br /> COMMENTS:,f 1 (�(545: Will !'Ll'r a re,r,(n.,,, n ?ajt,;% ;?a& _ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING a HOLLOW STEM DIA.OF BOREHOL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> a EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS <br /> TYPE OF CASING: D STEEL a PVC a OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEA6 S L 1,�TREMIE TYPE TO BE USED: O AUGERS OSE <br /> a AIR SPARGE/OZONE USH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPT Ig IS 30') <br /> OIL BORING a HAND AUGER GROUT SPECIFICATIONS - - - <br /> a OTHER:_D OTHER APPROX.BORING DEPTH D BOLT TRAFFIC BOX or a STOVE PIPE <br /> / CONDUCTOR CASING PROPrO�SED (if YES,list specifications in comment section) <br /> /� w! <br /> COMMENTS: �T•I tr- �i1LI14f Iv� roe (Z •f Z: <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 Ordinance , Ru l s?an egulations, and all applicable California State Laws. <br /> Signed x _Title/Company. ;W:Ad:erArrH;r 5 fL <br /> Print Name Date /�✓�{/4 <br /> DEPARTMENT USE ONLY / I <br /> SITE MAP IN UNIT IV FILE, ADDRESS: ar-c- to He COY / edCWA-CB <br /> WORK PLAN DATED: fJ 6/C — /I f <br /> Application Accepted By Date Issued��(*' Area d 6 6 <br /> Grout Inspection By Date Final Inspection Inspection By Date Final Inspection By e t° m Q�rt°�i Q�r <br /> Destruction Inspection Date <br /> Inspection Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# ZZ REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �- SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit=Encroachment doc±44 <br /> EHD 29-02-001 <br /> 6/22/04 <br />