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01/08/2007 MON 12:44 FAX • U002/005 <br /> COPY <br /> Ph41'+Y <br /> Q, (p ,;. San Joaquin County <br /> Environmental Health Department SITE <br /> h 304 East Wcbcr Avenue,3rd Floor, Stockton,CA 95202 J�rn MITIGATION <br /> i + V Y <br /> p (209)468-3449 Fax:(209)468-3433 Web: www..qjgov.org/ehd UNIT IV <br /> Well Permit Application G <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r'^'nTv,A/vv I9(/ <br /> Applicatlen 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 /> Assessors <br /> WELLLocationUV01GWl( C Cross Street Y YJ, CityPtam �dc-c P6674? <br /> nParcel# z9-/300$6 <br /> PROPERTW r I' t 1. <br /> Owner ai tGM k.G�- Address /C�� l+y.Cc,t ST City hjrxjA fe(-h Zip Y33P Phone ZO �3�^+' .s <br /> C-BT Contractor V W Dr�Address/00 5I Clly A—hziN zip956f( Lic#�2o909•Phone# �G � • IOU <br /> Consultant/Sub cntr�jt�o rl1./acJrrl,-•Addresal?D./y..wx3545� City S„ora uc# .� e24 Phcns# 3Z-03C1 <br /> GIS Coordinates:Xj 34 371,90 .Y ZIl3/r��•.�S'. ,Township TSS Ranga,,,.. G AE Section 1 <br /> WORK TO BE PERFORMED: <br /> Il NEW WELL/ BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') UIESTRUCTION (choose type below) <br /> Il SOIL BORING# VER-BORE, DIAMETER /Z". <br /> o WELL# a PRESSURE GROUT <br /> a'Other GROUT SPECIFICATIONS <br /> COMMENTS: _ <br /> TYPE OF__WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE IL p MULTIPLE CASINGS a MULTILEVEL WELL CASING DIA: 6 <br /> B EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING; U STEEL Q PVC BOTHER: <br /> 0 VAPOR U MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE U5ED: 0 AUGERS a HOSE <br /> II AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Il Yoe a No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30) <br /> d SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> a OTHER: R OTHER APPROX.BORING DEPTH u BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPOSED .. (if YES,list specifications In comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyOOrdinance$, Rules an Re ulations,and all applicable California tate Laws. <br /> Signed (!•1/r�� g r� i// / Ttla/company rti/IZ.a[t./r �p <br /> Print Name 96kollf �2/ . V DateA�a�oil., Aa <br /> DEPARTMENT USE ONLY y ,� <br /> SITE MAP IN UNIT IV FILE,ADDRESS: JAA <br /> WORK PLAN DATED: awe _T <br /> Application Accepted By Date Issued _ Area <br /> Grout Inspection By Date Final Inspection B " 2 ate �7 <br /> Destruction Inspection By ale 0 <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# F <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST It INVOICE <br /> SRO _D 1 /-12,-Q7 SR# 00 6 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 9/302003 <br />