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o *San Joaquin County RECV ED FILE COPY <br /> H Environmental Health DepartmeotT - 3 2006 SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202 ENT HEI+LTH SITE <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sj PSER%ES UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE 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 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 t22 -o VIA iJ-)C p Cross Street t�M��Sd�'r ' Cit 7(EAr Zf Assessors 3 <br /> Y p 537 Parcel# a0'1 -1(O 1 <br /> PROPERTY Tn �� <br /> Owner'/Y1i )5L,n c7L't)F CO Addressi•�9,)b VIA N1 s,r n City �aAP--Y ZIPJJ3;1 Phone# -Lt664=� <br /> C-57 Contractor-Y t L-) DIZ(LA k-)C� Address`vU QC�e Lt 1 6Ck ISI aQ Zi <br /> Y p15t41 Lic# Phone# 9te"t)74(no <br /> Consultant/Sub Cntr Address City Lic# Phone# <br /> GIS Coordinates:X ,Y ,Township .-Z S Range 2-%e, Section 3q <br /> WORK TO BE PERFORMED: <br /> )(NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER") p DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> IFWELL* 1, I 1 y ) 27 a OVER-BORE. DIAMETER <br /> Q PRESSURE GROUT <br /> Q"Other GROUT SPECIFICATIONS— <br /> COMMENTS: EV"JR- <br /> PECIFICATIONSCOMMENTS: EV"JR- —(-'I On- 7c7) I lOc7 <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> )(MONITORING 'HOLLOW STEM DIA.OF BOREHOLE a MULTIPLE CASINGS B MULTI-LEVEL WELL CASING DIA: V <br /> 0 EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS9-H Lf0 TYPE OF CASING: O STEEL $PVC BOTHER: <br /> a VAPOR n MUD ROTARY DEPTH OF GROUT SEAL S O V ff01 TREMIE TYPE TO BE USED: 0 AUGERS a HOSE <br /> 0 AIR SPARGE/OZONE u PUSH POINT(GP or CPT)GROUT SEAL PUMPED: )(Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS POP,-C C 7v 46N'r ti✓/ <br /> 0 OTHER: B OTHER APPROX.BORING DEPTH 212/ Z)I a BOLTED TRAFFIC BOX or STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: eao1 GbAL H7$a✓7' GU ' P'-R- 7y I a/Ez' S) RD' I og- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County dlnances, Ru/les and,Regulations, and all applicable California State Laws. <br /> Signed K dam. Title/Company -rv.V . I�//l�� ��2/rjG -� f��7� �• <br /> Print Name t E2n,4ryt S [ , I«}y--a-, Date_/ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: ZZSe r (� / <br /> Application Accepted By - Date Issued L Q�Ll d Area <br /> Grout Inspection By Date o6 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> *ACCOUNTIWNG ONLY: AID# <br /> FAC* <br /> CODESFEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SR#_ C=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc/v <br /> EHD 29-02-001 <br /> 6/22/04 <br />