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10/06/2004 16:54 2094671 AGE STOCKTON PAGE 04/04 <br /> • <br /> San Joaquin County <br /> z Environmental Health Department SITE <br /> 304 Fast Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> ` r (209)468-3449 Fax:(209)468-3433 Web: www,sjgov.orglehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRE5 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application Is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.7 and the Standards of San Joaquin County Environmental Health Department. <br /> ty � A AaEessora/ <br /> WELL Location61ar7erCfby Cross Street Ci ip 3e�10SPerceltt <br /> PROPERTY !Jr <br /> Owner flor►es `��Z./ _Address <br /> /��Ily„�QC��Ip]�f�M/y�_../!_-Phone# /� <br /> C-67 ContractordjJ J�--- �cess 237 Shtlt NL City JjoMW,cic*~hone# <br /> Consultant/Sub Cntr temli'Q Address ry.S/�o�/ Ciry�ICLica_v,—Phone# <br /> GIS Coordlnates:X .Y Township Range -.Section. <br /> WORK TO BE PER POSMED: <br /> atNEW WELL!BORING (CPT,GEOPROBE,HYDRORUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> T pdySOIL BORING i! C(p� aOVER-BORE. OIAMFTER <br /> jl WELL# 0 PRESSURE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTROC ION SP CIFICATIONS ,// <br /> 0 MONITORING O HOLLOW STEM DIA.OF BOREWOLE a MULTIPLE CASINGS O MULTI-LEVEL WELL CASING DIA:_'_�?_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPPEyEO�F CASING: O STFEL O PVC D OTHER: _ <br /> O VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL^ ter-D�,-f�.- FJOIE TYPE TO BE USED: XAUGERS 0 HOSE <br /> 0 AIR SPARGE/OZONE ?PUSH POINT(GP or CPT)GROUT SEAL PUMPED; O Yes O No (NOTE: MAXIMUM FREE-FALL PZPTH 15 30') <br /> OIL BORING p HAND AUGER GROUT SPECIFICATIONS PAp'�/gn!/ I�.r r<(//�/ <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH��: r (I BOLTED TRAFF OX or O STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Irf YES,Ilst speGflcatlons in comment�eotron) <br /> coNtMENrs: �OSAIL OrfnsS I114Y C! 20 14;—� 1 �o as" 7o Say duJAY,�t . <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 application and that the work will ba done in accordance with San Joaquin <br /> County Orfl' nces, Rules and Regul 'ons,an all applicable California state Layu -f <br /> Signed x illelCompany "hlLi.477 c,� [! <br /> Print Name- � (� 4ate���'Q r Y, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED:_ 10 G 1 — <br /> Application Accepted By I,�'t.ViDate issued!/;-- Area <br /> Grout Inspection By Date Final Inspection By_ Date <br /> Destmclion Inspection 8y Date <br /> COMMENTS ICONDITIONS: _ _14,46, �d +r- In <br /> - <br /> ACCOUNTING ONLY: AID* FAC* <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT I SERVICE REQUEST% INVOICE <br /> C-57_ WCC WA2VER_ C-57 Letter of Authoradtion to sign permit-Encroachment doc— <br /> FPID 29-02-001 <br /> 622104 <br />