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02/04/2009 WED 08: 41 FAX 20°4683433 SJC EHD 12001 <br /> ********************* <br /> *** FAX TX REPORT *** <br /> ********************* <br /> TRANSMISSION OK <br /> JOB NO. 2212 <br /> DESTINATION ADDRESS 915305892230 <br /> PSWD/SUBADDRESS <br /> DESTINATION ID <br /> ST. TIME 02/04 08:40 <br /> USAGE T 01' 06 <br /> PGS. 1 <br /> RESULT OK <br /> '`" ' \\ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SITE <br /> 600 East Main Street, Stockton, CA 95202-3029 MITIGATION <br /> Telephone:(209)468-3449 Fax:(209)468-3433 Web:www.sogov.org/ehd 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 Develo merit T!itle,chapter 9-1115.E and the Standards`ooff San Joaquin County Environ-mental Health Department. / <br /> l Location ��" .Q �7G�- '�( y , +GGy_ Zip Parcel#Assessor's <br /> ��T. <br /> Well Location G Cross Street Cit jA0iw <br /> Property /�� L ,/ Q / L / // <br /> Owner (T 4 i Address 3}S N�✓1`Ra� sl ��J City �Gcl1 CK Zip 79`f8 Phone# �,yy`17 11vn <br /> C-57 Contractor I�P0 Address, et AV,�i;kA G L City b"0 V; ! Q Lic#f yiZO��� Phone �3J Syp�,� Z(j/`% <br /> Consultant/Sub Cntr41 l Address 2_T37 /V i/+lG r71 Z1 City 6)Q n�l J#6sL6.yl�Phone�Ls z I ( soyo <br /> GIS Coordinates:X_�A 4_Jmorf Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) ❑DESTRUCTION(CHOOSE TYPE BELOW) <br /> 'KNELL# RINi# "1 ❑OVER-BORE DIAMETER <br /> PRESSURE GROUT <br /> ❑ -OTHER ElGROUT SPECIFICATIONS <br /> COMMENTS: 14 bA E <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS / <br /> ❑MONITORING ❑HOLLOW STEM DIA.gj�OREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA <br /> ??33 1 N <br /> [IEXTRACTION ❑AIR HAMMER/DRIVEN CASWOITHICKNESS 5C h q0 TYPE OF CASING:❑STEEL -PVC ❑ OTHER <br /> ❑VAPOR ❑MUD ROTARY DEPTH OF GROUT SEAL f� -TREMIE TYPE TO BE USED J(AUGERS❑HOSE <br /> ❑AIR SPARGE/OZONE *USH POINT(GP OR CPT)_GROUT SEAL PUMPED:❑Yes ANo (NOTE:MAX)MUM FREE-FALL DEPTH IS 30') <br /> ❑SOIL BORING ❑HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: ❑OTHER: APPROX.BORING DEPTHBOLTED TRAFFIC BOX OR [I STOVE PIPE <br /> CO DUCTOR CASIN RO SED (if YES,lis specs cations in npnenl section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE A CESS AGREPME ta- <br /> T/OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br /> I hereby certif.that I have,prepared this application and that the work will be done I accordance with San Joaquin County Ordinances,Rules and <br /> Regulations n all a ' able California Laws. �7 <br /> Signed a Title/Company �/LQ'�✓ ✓/�•y���y/jL—� A ') <br /> Print Name 6 Date 7 2,1 W'.w <br /> 1 _ DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:Z lL <br /> APPI Ir.ATIt7N A(`(.FPTFII RV A h"..lA ..i��.� it. � Wore icc���.�+ 'r I-r�nor <br />