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------ Qrccuv i)N1LLINU PAGE 02 <br /> NOUsa7-2007 11:22 'AMBRIA /-;z, <br /> �? �1 J _a.9 P.e21e5 <br /> Vii• <br /> San Joaquin County t',") <br /> x Environmental Health DepartmegNVIP . y L'tIj <br /> 600 East Main Street, tockton, UN61611 , r SITE <br /> (209)463-3449 Fax:(209)468-3433 Web: goo org/e�h�15�t /Sri NEAN TIGATION <br /> 1"1 I <br /> Well Permit Application <br /> NON-REFUNOMLE PERMR E XPIREa 1 YEAR FROM DATE ISSUED u <br /> APPtication in hereby made to San Joaquin County fora Permit to construct and/or Install Ire wort dosobed. 7nF9 appllcat)on IA made in pmpllenoe wile San <br /> uoaQuln County Development Title,Chzptcr 8.9119.3 and the Stpmdorda of�5a�n,J�oaqul�n,Courttir t Environmental Health 1rft nrnent. <br /> WELL Location h�� uti. C.C� �Idi CrmStreet <br /> -A= dd1.i'!�ItY���I�S [IIP lS�OL Par�rsre/470�2i4 <br /> PRO <br /> 0wrttlrj'Knwls\t ' LL <br /> C-57 Contractor4$ r <br /> Addreoo 1ky <br /> Consultant/Sub cntr <br /> :mac►N QQ;l�Lidt Pnorsea_ 7�7 Q3S'4Yi-O <br /> GIS Coordinates:x ,Y Townsh)pRange <br /> Section <br /> MIRK TO AQ P�RFQ wacp. <br /> Q NEIN WELL!BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTNr.R`) <br /> 0 SOIL BORING* DESTRUCTION (choose type twlow) <br /> )�2NELL#_M — o I10VER BORE. DIAMETER <br /> 0.Other -- 13 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATTONS_��_ <br /> aRE OF WELL l S7ALLATION TYPE jiQN3tRUCTION SPEQI <br /> YONfTORING P.ROLLOWSTEM DIA.OF A0QEHOLF&Ly MULTIPLE CASINGS lj MLILTI-LEVEL WELL CASING Ow: Z <br /> 0 D(TRACTtON a AIR HAMMER/DRIVEN CASING THICKNESS � <br /> 0 VAPOR TYPE OF CASING: Q STEELVC p OTHER: <br /> Q MIJD ROTARY DEPTH OF GROUT @EAt�R_,{ r TREMIE TYPE TO BE USED: ;aUGERS 0 HOSE <br /> 0 AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL BUMPED es <br /> 0 SOIL BORING 0 HAND AUGER �' D No (NATE; MAXIMUM FREE-C=ALL DEPTH IS 30') <br /> GRouT sPECIFIcAnoNs oil \ Vil <br /> 11 OTHER: n OTHERAPPROX BORING DEPT}i_ W 5 ' <br /> �O TED TtgerrlC SOX or lj STOVE PIPE <br /> COMMENTS:: <br /> CONDUCTOR CASING PROPOSEp — <br /> (7 YES,Yst speciflcagontt In comment section) <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 3PPlication and that the work will bs'lone In accordance with San Joaquin <br /> county Ord a R® ns,and all applicable California Stabs laws. <br /> Slpned. <br /> 'nI)NCornpany� <br /> Print Name r <br /> bets <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Gao i'✓, <br /> WORK PLAN DATED: <br /> Appll � L <br /> Grow Ilan Accepted 8 1�� �}��q J A�1� 'Date Issued // 13 -C�7 <br /> Groin Insptactlon By Arnay- <br /> Data_2=13-O S Flnaf InaPection Ely <br /> Destructlon Ing on By <br /> Date <br /> COMMENTS f CONDITIONS: <br /> rn _ <br /> ACCOUNTING ONLY: AIC,# <br /> FAGS <br /> PE CODES FEE INFO AMOUNT REMITTED CHB-Kr <br /> 3 5o t <br /> RECD my DATE, PQRMrr/SERVICE REWEST9 INVOICE <br /> �q,oD 89. o U <br /> 100 L !!-/3-07 S R# 005.2 <br /> C-57 WC`WATVEP C-57 Letter of Aurhorization to sign permit Encrcachmenr doc_ <br /> P-40 zo.oz-oot WEB <br /> 911112007 <br />