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10/27/2005 10:08 FAX 9166792900 URS-SACRAIIENTO-60 • [1002/006 <br /> • <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fate: (209)468-3433 Web: www.sjgov.org/ehd UNIT IV <br /> Well Permit Application <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 deecdbed. 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 Depenmant- <br /> Assessors <br /> WELL 1-0cation.Sld4 ? .41.HDr^ y Cross Street ' ryisa1b City 12MI601 Zlp Parcel* fCt�Gr�r<JLt map <br /> PROPER 1 brv6Wi 'dew r'K. pr'105r5rLQf-106) <br /> Owner- we/✓Aa I ddrese Seu4Df A7,2wAJ,40S Gity Zlp Phone# <br /> C57 Conlrecter G4rlr-& DQAtA4 AIS Addreea City.'/^Kn^�'L'Zlp <br /> Consultant/Sub Cnlr r/>C�'4~Dr",g%/ Address 2870 CCvO?8v AeKR Gity SA L. Lit# Phena# ?IL (r79-7�ata <br /> GIS Coordinates:X Se"--c.ae.anwJY AA Ar ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL/BORING (CP7,GEOPROSE.HYDROPUNCH,HAND-AUGER,OTHER") a DESTRUCTION (choose type below) <br /> XSOIL BORING# cl'rio96'-Gr-rtnbl a OVER-BORE. DIAMETER <br /> a"Other WELL# Cvf^rusi � Orrws�i ory ems!®v cP7•IOS�fI Oprjogg a FRESGROUT URE GR A OUT ONS <br /> COMMENTS: /9 CiorMt.ES�rt,rm5(,t(eccwv) 9 e,pr -OC~VShj„merecse.„o,-,r, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ,%1.10NITORING �i"OLLOW STEM DIA.OF BOREHOLE,�(J>_� 7ULTIPLE CASINGS R MULTI-LEVEL WELL CASING DIA: <br /> R EXTRACTION a AIR HAMMEFUDRIVEN CASING THICKNESS Sck 4D TYPE OF OA51NG: p 5TEEL XPVC a OTHER: <br /> R VAPOR AMUD ROTARY DEPTH OF GROUT$FAL 10-?a' TREMIE TYPE TO BE USED: AUGER$ R HOSE <br /> p AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: *Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS69,syAe '.J FAe.E To 40' <br /> 17 OTHER- p OTHER APPROX.BORING DEPTH %S 1 $� gSOLTED TRAFFIC BOX or AtTOVE PIPE <br /> CONDUCTOR CASING PROPOSED IN YES,list ep fcations In comment section( <br /> COMMENTS: rS�e- ��g' �U:es -GG.d7rlucT/tu l 7`A6r.EJ 1711/-!✓rO <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 46 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 Ordinances, RulesandRegulations, and all applicable California State Laws. <br /> Signed x_ �+ r`�" Nom— Tltla/Company '-�eZ,5 e-�4-p&a& 1&J <br /> Print Name_ or a120W✓� _ Dale 'VImR WA— 2-L�' Z�S' <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. <br /> WORK PLAN DATED: <br /> Application Accepted By "`" 1 I Date Issued lr r of D:- Area <br /> Grout Inspection By_ -N Date Ir 0 1 Final Inspection By '�t Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 GONDrrIONS: <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> S7OS (� lliL rr o� SRO pU LI Vit. <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29.02-001 <br /> 6/22/04 <br />