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man Joaquin Couch COPY <br /> Environmental Health yA);fhirtment RTE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202 INION <br /> (209) 468-3449 Fax: (209)468-3433 Web: www.sjgov.org/ehd OCT 2 6 2006 NIT IV <br /> Well Permit Application C O <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED CN E'"T ENpr1''H".E/�(_TH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This pppliccali� '1i Yatle�d�compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> (� 4 A� p A� Assessors <br /> WELL Location � / 7 ! 9 k n <br /> nOr :Un I Cross Street C�c .W Ave City LOIXZip K24I Parcel# OS5- /5-2(. <br /> PROPE TY <br /> Owner 2k TraLV Address N 60)(( /d03(e ityTisc Zipy-'37(e Phonne#204- 832-7780 <br /> C-57 Contractor /�t cc� Address/0/4 U 1 t^, Cit ' Yip/&J Lic#O�Phone# d <br /> Consultant/Sub Cntr AGE. Address 837 SkAa RU City$TC Lie* (802 7 Phone# R09-4A,-7- /00(- <br /> GIS <br /> 006GIS Coordinates:X 'y Township 3 N Range S>: Section )y <br /> WORK TO BE PERFORMED: <br /> 0,NEW WELL/BORING (CPT,GEOPROBE, HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# ` A 0 OVER-BORE. DIAMETER <br /> KWELL#VW-I,VW-I,UW-3r AW-I SAW-2 ��j �„y aPRESSURE GROUT <br /> 0*Other <br /> /7/ GROUT SPECIFICATIONS <br /> COMMENTS: 'tq� <br /> i <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING OLLOW STEM DIA.OF BOREHOLE O 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: ZAS2° <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL X PVC 0 OTHER: <br /> (VAPOR p MUD ROTARY DEPTH OF GROUT SEALMaX -10 ' TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> d,AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 'tNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS 1?or+I&4 (n Sack <br /> 0 OTHER:_0 OTHER APPROX.BORING DEPTH IS' + 15' ' BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED—N O (if YES,list specifications in comment section) <br /> COMMENTS:10" I7or;�q For SVE. + V" "c ino Yer ZAS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I by herece tha�t I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O a fes, Rul an egulations, and all applicable California State Laws. <br /> Signed x Title/Company Aaen4 FOt- A G <br /> Print Name Chris (rl. l�tr Date_ /0'a(,-0(, <br /> DEPARTMENT USEONLY / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: /C T 7'f %�L/7�CV7� P <br /> WORK PLAN DATED: Z!n OGr-lip <br /> Application Accepted Date Issued /O—Z7�L -6 Area Ov <br /> Grout Inspection By117,110kDate 1 7 Final Inspection By 6 <br /> Destruction Inspection Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# 'D BY DAT 5PERMIT/SERVICE REQUEST# INVOICE <br /> ZSs > 37 . 03 6fI SR# QD �D <br /> C-57 WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> EHD 29-02-001 <br /> 622/04 FILE COP Y <br />