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OW L1!10Uf 1b:14 2U94b83433 EHD PAGE 02 <br />. � Ulry � /�Jr• <br /> Sart Joaquin ounty UW4 � r) <br /> f x Environmental Heal h Department L��' �✓� 1—SITE <br /> 600 E.Main Street,Stockt ,CA 95202-3029 sFP ;� ITIGATION <br /> (209)468.3449 Fax: (209)468-343. Web:www.sjg�S°lgp p)1d Z�Q7 UNIT IV <br /> ' Well Permit Ap lication p�plY�til�,V'fFAIrH¢g4r - -�— <br /> NON-REFUNDABLE PERMIT EXP IRES t EAR FROM DATE ISSUED /SERki� <br /> Application is hereby made to San Joaquin County fora permit to construct and r install the work described. This application is made In compliance will <br /> Joaquin County Development Tithe,Chapter 9-1195,3 and the Standards ofSa Joaquin County Environmental Health Deparananl. <br /> Assessors <br /> WELL Location a S. Ce.�Cc cross Street !;jmV, 1,54. city S�.o A"N zip 95203 Parcels 10-d-J.e-aI <br /> ' <br /> PROPS N (PG� E` J413S <br /> Owner s'3Vo <br /> .Addreso $a. i Cityzp.-" Zlp�ISg.3 PhonalSVG- SF,s <br /> 0S7Contractor,p rLa"er� �' .,•n1'. Address -8i x �4e� ea z;94 01 u <br /> —�-y� Y P`_ Phonelt(S/o�2137-11575 <br /> ' Consuhant Sub Cn1r�xrw Pery�f+r Address `}� _ 1ityhA LirePhgne# �W35'�215-(/6o <br /> $u) g <br /> GIS Cdbrdioates-X ,Y ' ,Tovmshi Range Section <br /> WORK TO BE PERFORMED] <br /> ' (MEW WELL f BORING {CPT(G ROB , ROPUNC D- G OTHER•) p DESTRUCTION (choose type below) <br /> .,.'SOIL BORING* 12 p OVER-BORE. DIAMETER <br /> a WELL# p PRESSURE GROUT <br /> a Otber GROUT SPECIFICATIONS <br /> ' COMMENTS; I Tl 1.x 1� <br /> TYPEQF.WELL. INSTALLATION TYPE CONSTRUCTION SPE 1 ICATIONS <br /> ' 0 MONITORING 0 HOLLOW STEM DIA,OF SOREHOL p MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> {I EXTRACTION p AIR HAMMERfDRIVEN CASING THICKNE$S TYPE OF CASING: d STEEL 0 PVC []OTHER: <br /> D VAPOR Q MUD ROTARY DEPTH OF GROUTS TREMIE TYPE TO BE USED: C AUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMP d Yes 13 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> ' YS014 BORING p HAND AUGER GROUT SPECIFICATI I S <br /> 11 OTHFIT,_,��Q.t)THER _ APPROX,BORING DE H BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASIN ROPOBED (if YES,list spedfications in co mein section) <br /> ' CgMMENTs: G <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS kGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE F EQUIRED FOR INSPECTIONS. <br /> ' I hereby certify that 1 have prepared this application and thal the work will be done in accordance with San Joaquin <br /> County Ordinal s, RUI s a d Regulations,and all applica California State Laws. ({++ /' <br /> ' Signed x� ,��. Yh Compan �4�r1'QLT Q'xf•11 ee�� <br /> Print Name DateetT`— <br /> OEPARTME USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Avoepled BY Data Issued ..Ol Area S l l <br /> Destruction inspection By Data <br /> ' COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLYr AID# FA <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RE DBYE."�A,.:E <br /> PERMIT I SERVICE REQ UEST# INVOICE <br /> oD �� F SR# o s"2o <br /> C-57 Letter of Authorizat n to sign permit_Encroachment doe— <br /> ' EHD29-02.001web <br /> nn <br /> _VO4 <br />