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02/17/2006 14 10 2094663433 EHD PAGE 04 <br /> ' San Joaquin County <br /> pZ <br /> Environmental Health Department UTI <br /> i 304 East Weber Avenue,3rd Floor, Stockton,CA 95242 <br /> (209)468-3449 Fax (209)468-3433 Web www s o ION <br /> • 1�ov org/ehd E��I'P Nl�y UXv <br /> Well Permit Application ��i FIVT <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 Oescribed This application Is made in c0mplianoe with San <br /> Joaquin County OevefOpment Tdte,Chapter 9-1115 3 and the Standards of San.loa4um County Environmental health Department <br /> MILL Location "c, o� 2`lv� Crass Street�� ZIP ssess i <br /> PROPERTY �_ } <br /> Owner -a�Addresss ` <br /> ���*"��mC+ty S�yrk�,, zip clS'LozPhone# <br /> P57 ContracIor ' <br /> �..' _C..o.,`ti� 5,, CI �4'-dc>+n� epic# 9"_S$rrone# °►ib 8 -t1b9 <br /> Consultant lSubCntr� �ay�ddress gg <br /> �'i �+[ tic City�,o LIc* Phomr <br /> GI-5CoordinatesX -a � <br /> Y Township <br /> Range Section <br /> WO K TOE PERFO MED <br /> fl NEW WELL!BORING (CPT,GEOPROBE HYDROPIUNC 1 HAND-AUGER OTHER• <br /> OIL BORING v ) fl DESTRUCTION (choose type taelgw) <br /> Q VVELL 9 0 OVER-BGFtE. DIAMET <br /> n'Other 11 PRESSURE GRO(jT <br /> COMMENTS GROUT SPECIFICATIONS <br /> TYPE a� INSTAL!_ATtOm TYPE CONS TRUCTiDN 8pEC3FtCAT10NS <br /> fl MONITORING 0 HOLLOW STEM DIA OF BOREHOLE <br /> 0 EXTRACTION Tl AIR HAMMERJDRfVEN CASING THICKNESS 0 MULTIPLE CASINGS fl MULTI-LEVELt/4EL.L CASING DIA. <br /> {]VAPOR fl MUD ROTARY -- .—�-TYPE OF CASING (3 STEELUPVC I]OTHEFL <br /> DEPTH OF _ <br /> GROtIT 5 L_� TREMIE TYPE TO BE USED <br /> Q AIR SPARGEr OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED fl AUGERS d HOSE <br /> • '� <br /> SOIL BORINGfl GROUT SPECI <br /> HAND AUGER t1 Yes Il No (NOTE MAXIMUM FREE-FALL DEPTH IS 301) <br /> FICATIONS <br /> fl OTHER 11 OTHER APPROX BOR <br /> fNG DEPTH 2-p' <br /> (I BOLTED TRAFFIC BOX Of V STORE PIPE <br /> CONDUCTOR CASING PROPOSED {if YES,list specifications In COMMENTS � canunent sedron) <br /> c <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HQUk$NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby Certify that I have prepared this application and that the work will be dome in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x TKWComPany <br /> Print Name <br /> Date !S <br /> Dr= ARTIVIENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; Z <br /> WORK PLAN DATED, o <br /> A%AC2 don Accepted By Date Issued p <br /> Am <br /> D09QrMt2lon I sp By. Date Fina[Inspection By <br /> Destru�tion lnspectlotl8y Date - Ddte <br /> COMMENTS I CONDMONS: <br /> ACCOt,IfMNG ONLY A1D# <br /> FACIA <br /> PE CODES FEE INFO AMOUNT REMnTED CRECK 0 REC"D RY DATE p <br /> IR11GT1&ERVIGE REQUESr# INIfDfCS <br /> iso N 4ktj DC7 �`{Z3of z I�(o� SR# Ll 5�5 <br /> •C-57 WC!_ WATVER_ C-57 Letter of Authorization to stnInit <br /> En <br /> �a-02-W 1 Ct`04Clitllt�nt dot:"_ <br />