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U°31EGESVED • 0 <br /> NOV 2 0 2006 <br /> ENVIRONM ALTH San Joaquin County <br /> PER : t Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.org/ehd UNIT IV <br /> =F�""' Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <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 compliance with San <br /> Joaquin County Development Tiae,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 1�iS�T/!l Ls&''' i Cross Street CRy 5d' ts-Z'0 Assessors�^�ParceHt_144�ti�t _f0 <br /> PROPE <br /> Owner Address �f�0 S'r'J�YC-StC�(Ciq Say. ZipISCLIPhone# r//S Z57-8SY0 <br /> C-67 Contractor -TELA Address�l(3SO V('irrkiaP/�P/_Cit RfaM 9w WtS Phone#RfbSS58alO_ <br /> Consultant/Sub Cntr Address 2Wr.rn. Ciry46ft'& 'e c# Phone# 70�ST{3�-f Z�. J <br /> GIS Coordinates:X Y ,Township Range Section <br /> BEORMED: <br /> EW WELL/PERFBORING (CPT, EOP HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> QSOILSORING# 4F OVER-BORE. DIAMETER <br /> Q WELL# Z OVER-BORE. <br /> GROUT <br /> B'Ouwr GROUT SPECIFICATIONS <br /> COMMENTS: Sa'� k4e;";t -& /n-d.2 XA /14g ijpzj�&V i ji 41, 7a 3;5 <br /> TYPE OF WELL IMSTALLATON TYPE CQNSTRUCTION SPECIFICATIONS <br /> B MONITORING n HOLLOW STEM DIA.OF BOREHOLES Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> n EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS--.A/11 TYPE OF CASING: Q STEEL Q PVC B OTHER: <br /> Q VAPOR B MUD ROTARY DEPTH OF GROUT SEAL_(01 m 30' TREMIE TYPE TO BE USED: Q AUGERS Q HOSE <br /> B AIR SPARGE/OZONE'jkPUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> j OIL BORING Q HAND AUGER GROUT SPECIFICATIONS W(L/-rT C&--)"EA-)T <br /> Q OTHER:_Q OTHER APPROX,BORING DEPTH 9 BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR C SING PROP"O�SED (# YES,list spe0r, in comment section) <br /> COMMENTS: 71A �yOi%��J;JI d, �.C�y,�jQ � .F,c4 ��T <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Or <br /> d* nc/ee Rut and Regulations,and all applicable California State Laws. <br /> Signed x ,i//G�����O �.nfea Tlae/Company �� <br /> Print Name VJHL E' 4eq&3�? pate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,t�DRESS: I�� Tatt-t LA4-Wtn 1), <br /> WORK PLAN DATED: l l b too6 <br /> Application Accepted By Oi _Dale Issued Itk-t 04 It'-t04Area <br /> Grout Inspection By LL,)A/ti Ar'C A Date 2,o t�L, Final Inspection By 2 Date n e 6 <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> X901 140.06 Isbg9(9d91 IGD Is u 4 SRO c�c�`L 5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/94 <br />