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01/08/2007 MON 12:45 FAX U 74/005 <br /> • FILE fto [r7 <br /> vi <br /> ;oai�;�.,y..�• San Joaquin County <br /> fiZ.GGA ,II '!I� 4 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,.qjgov.org/ehd UNIT IV <br /> Well Permit Application �^/��',/A/ <br /> NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /rv''vv_ <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 Tills,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELLLocatlon 2-40 W. osevvi I1 Cross Street�ir rr>� City mo"l"i.GK Zip 9533r`parcel# <br /> OERt <br /> OOvwner <br /> (-, M M Address/RO/ JJ CemI--r °it, CityIyoMftU- Zlp�31 Phone# 0 Z31- 3 <br /> C-STConvaotor VW Thilllnclr,t, ddress/Dy Fi1fA St. Cny ele&vn Z1p95641 Lic# 0904 Phonal % 2 00 <br /> Consultant I Sub CntrGondar City. ons ro. LickiZIOU Phone# 0209 5-j2:e16/ <br /> GIS Coordinates:X G3425Z .GG ,Y 2ll L543,/3 Townshlp7-2 5 Range 1*'6� section / <br /> 49RK TO BE PERFORMED: <br /> NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 11 SOIL BORING# O OVERBORE. DIAMETER <br /> (ii # MW-77— n PRESSURE GROUT <br /> a"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE PE IFICATIONS <br /> (AONITORING �rfOLLOW STEM DIA.OF BOREHOLES n MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA <br /> u EXTRACTION n AIR HAMMER/DRIVEN CASING TI IICKNESS Selr 40 TYPE OF CASING: 0 STEEL 3PVC 0 OTHER: <br /> p VAPOR a MUD ROTARY DEPTH OF GROUT SEAL CDL TREMIE TYPE TO BE USED: U AUGERS a HOSE <br /> 0 AIR SPARGE1 OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 You 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n SOIL BORING E HAND AUGER GROUT SPECIFICATIONS necks Cl bg r c <br /> a OTHER: p OTHER - APPROX.BORING DEPTH ZZ" n BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED NG (d YES,list specifications in comment section) <br /> COMMENTS: <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+Orinjnoua, Rules a d Regulations,and all applicable California SState Laws. <br /> TTiOelCompany�.4A Date-/&A&" <br /> DEPARTMENT USE 9NLY p <br /> SITE MAP IN UNIT IV FILE,ADDRESS' �(� d/ <br /> WORK PLAN DATED: 0 6 <br /> Application Accepted By Date Issued 1Z — Area <br /> Grout Inspection By / to7i Final Inspection By _ Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE <br /> REQUESTT# INVOICE <br /> SR# !� 0 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/302003 <br />