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05/02/2005 16: 08 209468: FIFTH FLOOR PAGE 02 <br /> RDWELL PERMIT APPLICATION FORMEgDD <br /> SITE <br /> AUG 2005 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMEN1 lihA,Lfli 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> PEi�1IT/SERV S (209) 468-3449 <br /> Application is hereby mads to San Joaquin <br /> NON-REFUNDABLE PERMITEXPIRES 1 YEAR KROM DATE ISSUED <br /> 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 /> WELL Location 9 <br /> MfV c� Hyl�j 1176 - t -(9055 Street G t� Sfr Assessor's <br /> �� City I✓CSC: Zip_��3� Parcei#_ <br /> PROPERTY Owner(ly,,o,� r GiCi�i c 2Gil rec,c� Co Address i4o 0 1)o Ltc lG5 s�r City.Qvyu,�a ,IJP zip (0 8 _fi` <br /> ��Phone# 402 .9N'f-86o0 <br /> C-57 Contractor T�Ca-Nn0i„frn Cr.ii r,i(Addresslt3S0 Mcrl;c,- Pc,,.k <br /> .t"N,L �C—ZiP!5-14 L;c o[sG8 Phone;�ttb� S3- Cio <br /> ConsultantISub Contractorele.:e,�,� Ca suite etc' 12"„cl o <br /> nsul-tants Tnc. Addres93i(oo raoldli,Uz ��-. City c r,, L Lic# Phone#C��6 BSL-�111g <br /> Gla Coordinates.X Y Township _Range— <br /> _Section <br /> WORK TO BE PERFORMED: <br /> 'ZftEW WELL/BORING(CPT,GEOPR�IYDROPLJNCH.HAND AUGER OTHER`)SOIL DESTRUCTION(Choose type below) <br /> 11 WELL# 0 OVER-BORE <br /> 'Other: Grout Specifications: 4-PRESSORE GROUT <br /> COMMENTS: ' + <br /> TYPE OP WELL INSTALLATION TYPE= CONSTRUCTION SPECIFICATIONS <br /> f1 MONITORING 0 HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?[]YES ONO WELL CASING DIA; <br /> EXTRACTION D AIR HAMMERIDRIVEN CASINGTHICKNESS <br /> TYPE CF CASING; Q STEEL D PVC []OTHER: <br /> VAPOR, MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; 0 AUGERS 0 HOSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED; 0 Yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 13 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> p OTHER: 11 OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'COMMENTS: <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE:UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work Will be done In accordance with San Joaquin <br /> County Ordinances, Rules and <br /> nn^Regulations, and all applicable Californla State Laws. <br /> Signed X__, 1.1i� // � L 71fe/Company C Ca nS tt(tap1 G. <br /> Print Name GEMMA RL�L_AQO Date okcl� 05 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS. <br /> WORK PLAN DATED' <br /> Application Accepted By Date Issued <br /> Grout Inspection By Date q 1 240 Final Inspection By L, ate <br /> Destructlon Inspection ByDate <br /> cr 107 <br /> COMMENTS/CONDITIONS: 4 Q/ <br /> ACCOUNTING ONLY: AID# w`I L' °`^ S ; nS �C - e� .(y r <br /> �er� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECID BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> Z9G' e7 . <br /> 00 u 51 3 z y lie�3sR <br /> C-57 WC -WAIVER C-57 Letter of Authdrizatr' n o sign permit Encroachment doc 1/25/02 <br /> L1 �G--o—ly S r a V <br />