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11/03/2006 12:26 2094683433 END PAGE 02 <br /> i <br /> San Joaquin County, a <br /> VVP Environmental Health Department <br /> { <br /> 304 East Weber Avenue, 3rd floor,Stockton,CA 95202 OCTID6TI®!V <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov,org/ehd i UNIT IV <br /> P�RM Well Permit ApplicatApplication �I1lIP0 1 ai rr� <br /> 17`/;SE�Vl��S <br /> NON-REFUNDASL8 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 9A 115.8 and the Standards of San Joaquin County Environmental Health Department. <br /> Y T I Assessors <br /> WELL Location}tU"4 Rr �1C-ferta-Cross Street L°t�CJ �� �dl Lily�•� _Zip gl5-330 PWcel# <br /> PROPER 1� [�i <br /> Qwner YdfiIr � !_Address I'm po �D�,f) /�c✓,r eY-C y G �{`6� Zip7S33b Phone# <br /> C-57 Contractor. Vf W Qf'1�,wS Address,v,,, !®6 �Gt v7 le I tarty l�Ao Zlp i bY�Llr# Phanelf �(7"17-I/ <br /> Consultant I Sub Cntr 4 �°�A er Address <br /> GIS Coordinates;X ,Y Township Range Section <br /> WpRK TO BE PERFORMED: <br /> NEW WELL I BORING (CPT,GEOPROAE,HY DROP L]NCH, HAND-AUGER,OTHER") ,ADESTRUCTION (choose type below) <br /> I]SOIL BORING# $OVER-BORE. DIAMETER) !B�� <br /> $VVELL 9 0 PRESSURE GROUT 7 <br /> r]*Othor GROUT SPECIFICATIONS i S mil! <br /> COMMENTS: 7riv� III ehr� �1�0E <br /> . i <br /> ,TYPE OF WELL INSTALLATION TYPE CONSTRUCVPN SPECIFICATIONS IJ <br /> - MONITORING 0 HOLLOW STEM DW OF BOREHOLE !O� d MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA:_�w <br /> EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS 5410 TYPE OF CASING: a STEEL 9PV6 Q OTHER; <br /> 17 VAPOR d MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ;a AUGERS 0 HO$E <br /> 1]AIR SPARGEf OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED; ' Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH 15 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS 7� yr¢ 41 41_Ceke ' <br /> 0 OTHER: 0 OTHER APPROX,BORING DEPTH BOLTED TRAFFIC gOXI or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (It YES,list specifications to 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 Sari Joaquin <br /> County Ordinances, Rules and Reg cations,and all applicable California State Laws. <br /> Slgnadx Title/Company /d'D�C'� <br /> Print Nam /Y rt�CfS L°Ccb(/ pate Ib � io <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRIES, <br /> WORK PLAN DATED: C 0 <br /> Appiloation Accepted By Date Issued _�p r Area <br /> Grout Inspection By TJate� 1 I - 3 a Final Inspection By ! to Z1 <br /> Destruction Inspection 8y 4 Date <br /> COMMENTS I CONDITIONS; <br /> ACCOUNTING ONLY; AID# PAC# <br /> PIE CODES FEE INFO AMOUNT REMITTED CHECK# RI C'D aY DATE , PERMIT SERVICE REQPEST# INVOICE <br /> C- WC_ -WAxVFR, , C-57 Letter of Authorization to sign permit Encroachment doc <br /> 3 <br /> EHD 29-02-001 <br /> 6�2f04 <br />