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r _ � FILE COPY <br /> San Joaq;pirMou'fity - <br /> ' 8 n Environmental Health Departmer%[ECE,""y SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> ' (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.org/dWd, ' Q 2006 <br /> �•� _><:: � UNIT IV <br /> 0. <br /> b Well Permit'Application ENVI�GNMLE T #!� R <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUF6Rr01TISERVICES <br /> i:'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 /> 2yZ fJD !Vy IA1�I I P-� ' p� Assessors <br /> s'WELL Location Cross Street City oVh o Yt Zip �(O$•fO parcel# 0 0 I <br /> pYPALA r+-T <br /> PROPERTY F <br /> Owner L1NIVr�YSmr( FDVcS Address20$I E. I�,eI41IMe I`!g-- CityLjyANj VApisZip���JL�phone# tdllp-3b'�' f/Itil <br /> i1IC-57 Contractor WOOJVV:V4 DVr11rhSAddress fo•&aX 33tL CitY- l-I tS+Q Zip94511 Lic#71ao'7gPhone# '707 37�{-43ot <br /> 1`Consultant 1 Sub Cntr I C e S Address P 0- g Q X 2$B Ci yv li Lic#CO3q-70-7 Phone#_S�1 O L,15 z S-,? <br /> i� <br /> 0 GIS Coordinates:X Y Township Range Section <br /> t; <br /> WORK TO BE PERFORMED: <br /> '�-114NEW WELL 1 BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> Q OIL BORING# : Q OVER-BORE. DIAMETER <br /> HELL# AA —T„ D#t I Q PRESSURE GROUT <br /> Ei Q'Other !V GROUT SPECIFICATIONS <br /> COMMENTS: <br /> � TY E OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE �� MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS b•01y 11 TYPE OF CASING: Q STEEL ij 'VC OTHER: <br /> Q VAPOR OM UD ROTARY DEPTH OF GROUT SEAL I r '14,� TREMIE TYPE TO BE USED: AUGERS 'Q HOSE <br /> _Q AIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ,y Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> J.Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS N Ca f C'c-M ct't 'f-- <br /> 1 Q OTHER: Q OTHER APPROX,BORING DEPTH `I'ar OOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> ICOMMENTS: <br /> �f <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> r r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord ina�Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company 1-I h G l p:L.1 Ytxi(!V1 �7/ / I C 2S <br /> is r <br /> Print NameL-e-00q +. Date <br /> 1j DEPARTMENT USE ONLY. <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �k ?,-6O X10 Uj ec(- b <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued 'lv ' ,Q ,�Y �grea <br /> Grout Inspection By Date Final Inspection B <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# C` <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE I <br /> SR# Im <br /> C-57 WCC WAIVEP C-57 Letter of.Authorization to sign permit Encroachment doc�J I <br /> iEHD 29-02-001 << <br /> 6122104 <br /> r <br /> __ it <br />