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- JAN. 30. 2007 10: 51AM CO-WR EARTH TECH — N0. 1096 P. 2 <br /> Y 1 V)San Joaquin County <br /> Environmental Health Department nE'AWO <br /> ,r <br /> 304 Fast Weber Avenue,3rd Floor,Stockto 95202 : MITIGATION <br /> (209)468-3449 Fax,(209)468-3433 Zbb;- it <br /> L <br /> JehdC0PyjANLMTW7 Well Permit Application EN E <br /> NON-REFUNDABLE PERMIT EXPIRES q YEAR FROM DATE ISSUED PERMIT/SEFMCES <br /> Application Is hereby made to San Joaquin County for a permit to Cots1ruct andloT install the work des-mbed. This application is made h compliance with San <br /> Joaquin County Development TWO.ChapteT 9.1116.3 and the Standards of San Joaquin County EnAlronmental Health DepaMlent, <br /> WELL Location 30 rt 1 CrgSs Street^^fi�t 6z,,-r Cq s�� Assessor: <br /> L—.� tY A Zip 95-�ci2- Pam w# I�9-��Q+1 <br /> PROPERTY <br /> Owner—A ck tf fit#A A Lrefmr. Address 7 �� n er' city—Litc4 'ti Tip mza phone z 9 �f 6�a—e on f <br /> C-57 Contractor Lr IDAIfl'- ,address-.104 1"� f�Sf GtyLjjjf�, z;pgggj Lj di ar'90WPhv..&J-b777-111011 <br /> Wir Consultant/SubCntr n <br /> Address F3r�Wx C <br /> ity_ 7--L Llcl� Phone# 0 z�'lJ^dS/I <br /> GIS Coordinates:X ,Y ,Township Range Section <br /> ,,WORKTQ13EPEMF �?- <br /> a HEW WELLCPT,GEO OB IYDROPUNCH,HAND-AUGER,OTHER*) flDESTRUCTION (Choose type below)i1 SOIL 9r 7fY3 lI OVER-BORE. DIAMETER <br /> a WELL# G PRESSURE GROUT <br /> I`other W GROUT SPECIFICATIONS <br /> COMMENTS- Pr r c r,�7� S '� �s r 7Z' c„• o'' -c-t'rdc S/Z. a .rve���lt/fir <br /> TYPE OFLL rNSTALLAnoN TYPE CONSTRUCTION,SPECIFICATIONS <br /> 9 MONITORING U HOLLOW STEM DW OF BOREHOLE 2'-0 MULTIPLE CASINGS 9 MULTI-LEVEL WELL CASING DIA: <br /> R EXTRACTION R AIR 14AMMEPJDRWEN CASING THICKNESS TYPE OF CASING: <br /> D STIR Q PVC Q OTHER; <br /> ,XVAPOR d MUD ROTARY DEPTH OF GROUT$ � _.TsFMIE TYPE TO BE USED° (I AUGERS Q HOSE <br /> []AIR SPARGE! <br /> � OZONE� SH POINT(GP or CPT) SEAL PUMPED: pYesUto (NOTE: MAXIMUM FREE-FALL DEPTH IS 3b')SOILBORING IHAND AUGER GR0UTsPEGIFICATON _ b <br /> lit ±— <br /> Q OTHER:__________fl OTHER APPROX.BORING DEPTH <br /> Q BOLTED TRAFFIC 80X or A STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (d YES,list specifications in Comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Reufations,and all applicable California State Laws. <br /> Of <br /> Signed oil( <br /> TltlelCompanY [p /0. !Cp n r,=A <br /> Print Name !o i!I O a &7r <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; '73 S+ re ej <br /> WORK PLAN DATED: 24 2 <br /> Grout Inspection <br /> E3y Vit.+ r Date Issued—, 3 a 1 S9 <br /> Grout Inspection BY Date L p Final Inspection By Yr- Aac,Date <br /> Qestruction Inspection By <br /> Date _ <br /> COMMENTS/CONDITIONS: r� w I Q <br /> [ACCOUNTING ONLY: AtDi• FAC9-ODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY nATEP>=RMIT1 SERVICE Ri=Ql765T# INVOICE <br /> -z0seo 37�l-. 00 r �i SR# S89 <br /> C-57 WG--WAIVER— C-57 L¢tter of Authorization to sign pe6lf Encroachment doc` <br /> EYm 29.02.001 <br /> 6*2/o4 <br />