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U� San Joaquin County � �� <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202)UN 0 5 2006 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: rwrwrw.sjgov,org/ehd UNIT IV <br /> Well Permit Application ENVIRIONMEI;iT HEALTHPERM T/SERVIG <br /> ES <br /> NONREFUNDABLE 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 described. This application Is made In compllance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> (� 1 \/,,j �f /l Assessors I <br /> WELL Location T 1 4 i`GS AVr'. Cross Street I��, QLD eA City �t�L Zip �1 r3 41 Parcel#PROPJ 3 <br /> _ Ave- r� � � <br /> RTY <br /> OwnnerEWali-er nAI PCS' �Addrass I o�( �aA Acity �t fxr. _zip r3�6 Phoned( ZOQ <br /> M k Dt ;111n Address "'f/g1 �I&�!S P�GicQ U"((e �SZr�1 3W41 <br /> C-57 Cvnlractvr t !5 C 11 City Zlp Lic#b Phone7U f } �j <br /> Consultant I Sub Cntr— Address CityJ _Lic# Phone# <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TQ BE PERFORMED: <br /> NEW WELL/BORING (GPT,GOPR BE. DROPUN ,HAND-AUGER,OTHER*) 0 DESTRUCTION (choose type below) <br /> SOIL BORING# oZ 0 OVER-SORE. DIAMETER <br /> 0 WELL# p PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: — <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPEGIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE C1.1 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY , DEPTH OF GROUT SEAL_TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE I PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1 SOIL BORING O HAND AUGER GROUT SPECIFICATIONS Me-moi C'?Me n� <br /> l T <br /> W OTHER: q ru 1ALV 0 OTHER APPROX,BORING DEPTH �7 (7 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C NDUC7QR CASING PROPOSED (if YES,list specifications in comment setfor�l� <br /> COMMENTS: C���pr'�I h r ��� (1( � tc�r Sc; j k c� S(af�wl�S P YNAENN <br /> P'EC� <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMI,T§. 6 <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. JUN <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with S%kwdCOUNTY <br /> VI MENI AL <br /> County Or ces, s and EN <br /> Re ulations,and all applicable California State Laws. HEALTH DEPARTMENT <br /> Signed x �-- y_ TitIc1Cvmpany—.-? <br /> � <br /> Print Name �� � �r o'�! Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: I S Z I otnn �-o S R t (w�lU <br /> WORK PLAN DATED: 6 0 <br /> Application Accepted By DateIssued, 6,/bk;2 Area <br /> Grout Inspection By Date Final Inspection By Date <br /> Debtructlon Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> x`10\ SR# <br /> C-57_ WCC WAIVER_ C-57 Letter of Authorization to sign permit Encroachment doc— <br /> EHD 29-02.001 <br /> 6/22/04 <br /> Z0 39Vd SL90SC860Z SL90S8860Z Ob :SZ 900Z/S0/90 <br />