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COPY <br /> San Joaquid Coltnty <br /> 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.sjgov.org/ehd 2006 JUL -5 <br /> Well Permit Application S A 114 .10,; v <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV I R 0 f i m E N T AL <br /> HEALTH DEPARTMENT <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 <br /> Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location r�AiVet,s.. �4A „4 Yr �� NA <br /> Cross street ��-� 1 Assessors <br /> (l� city zip �33 u Parcel# 1 3 r 3 <br /> PROP ��OT 4. Bw4W Aaa @wart JQd jW�{1oa <br /> Owner ER 1 Ver`�.S larlas Address -2 1 <br /> J 7p�1� $TLWdf°7 Rd City LA� tb ZIp9s33oPhone# <br /> C47Contractor Or'%V!t .r•+ Address F►o.bcoc 41� QCtiyZ'e11% Zip V41LI Z69o4Phona# <br /> Consultant/Sub Cntr d Vm AddressQ�Qx® (�,lhyi.]01VICity Lla—w-&—PhoneO <br /> GIS Coordinates:X ,Y Township Range Section <br /> WORK TO-RE PERFORMED <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') ll DESTRUCTION (choose type below) <br /> (]SOIL BORING#_ I OVER-BORE. DIAMETER. <br /> a WELL# r a PRESSURE GROUT QJ <br /> Q*Other GROUT SPECIFICATIONS Ah ®®" <br /> COMMENTS: hlb bnrmd- REVCat'nei-12144.1, <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION jP90FICATIONS <br /> X'MONITORING j40tOLLOW STEM DIA.OF BOREHOLE_of a MULTIPLE CASINGS p MULTI-LEVEL L CASING DIA: V t I Acl- <br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL VC a OTHER: <br /> U VAPOR ' a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: []AUGERS 0 HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yea p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> H SOIL BORING la HAND AUGER GROUT SPECIFICATION <br /> a OTHER:_a OTHER APPROX.BORING DEPTH, ^_[]BOLT!<D TRAFFIC BOX or O STOVE PIPE <br /> `,, L1 CONDUCTOR�A SING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: )Je �Ilb� �CY>oWY1 4b V, CoM-QCAl'Mae,,A <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify t t I v : repared this application and that the work will be done In accordance with San Joaquin <br /> County Ordi and egulations,and all.applicable California State Laws. L <br /> Signed x Tttle/Company. S�TT "&--- i r/ E J�Qea �wC, <br /> —�— 4-4 , <br /> Print Name RIcNARD Date ' t..al•l 3, 200� <br /> DEPARTENT;,USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: ,Cj•b <br /> Applicaton Accepted By Date Issued • �is____� Area 0 <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST#. INVOICE <br /> 00, <br /> C-57_ WC -WAIVER C-57 Letter of Authorization to sign permi _Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />