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10/10/2006 16:36 2094683433 <br /> EHD PAGE 02 <br /> C APPLICATION FORM SITE <br /> NEDWELL PERMI TION <br /> SAN JOAQUIN COUNTY <br /> T 2 20H ENVIRONMENTAL- HEALTH DEPARTMENT {EHo) UNIT A <br /> TIGA <br /> IMSNI HEALIti3�4 E.Weber, Third Floor, <br /> Stockton, CA., 95202 <br /> ERVtCES (209) 468-3 9 <br /> ENPERMITt IT EXPIRES 1 YEAR FROM DATE ISSUSD <br /> NON REFUNDA$>E PERM application <br /> is made in Campllance�vitn San <br /> uin County Environmental Health Department, <br /> plication Is hereby made to San Joaquin County for a permit to construct andlor install'the work described- T�'i�s app <br /> aquin County Developmen[Title,Chanter 9-1115.3 and the Standards of San Joaq i q55 t parcels _ <br /> nL Cross SEreet �•' 'N �` City —zip <br /> Phon <br /> =LL Location.35 <br /> 'Ic l -`�2 <br /> p 9 � i7lr� G�IZ,ip ) e <br /> toPER } f r b�' U <br /> vner fir_�� ^QSt�l�tt� tLl. Address ) �J�,' �one#�!3�-�� 5yL'Y� <br /> 11' 35..0, iid5 r;y�. _city �icGd Zip_ ' � ' 7 - <br /> I il. Address____ : � 1 �p yrl�A1 PhoneR <br /> 57 Contractcr t'rL D 1� yt- �•� V]1'F,$v� L�+ fec <br /> � Addresd s <br /> msultant!Sub Cntr� Range Section <br /> IS Coordinates:X <br /> Y ,Tawnshia <br /> OTHER') [i DESTRUCTION (goose type below) <br /> dRK TO BE PERFORMI L7: 0 OVER-SORE, <br /> 'uE�1(WELL/ BORING ?T,GEOPR06E.HYDROPUNGH,�D-AUGER, <br /> �501L BORING <br /> 0IAMa"ER—�— PRESSURE GROUT <br /> GROUT <br /> a WELD <br /> A��ff'Ocher "L` II fLl CJ! <br /> PECIFI 71ONS <br /> YPE OF WELL IN Ta.LLATIQNTYPE CONSTRUCTION SPECIFICATIONS <br /> WELL CASING CIA: <br /> MONITORING HOLLOW STEM <br /> DIA. OF BOREHOLE,_ 0 Pr1ULT1PLE CASINGS (]MULTI-LE�/E1- <br /> PVC' Ij OTHER: <br /> In 14TYPc QF CASING: 0 STEEL wa -_— <br /> EXTRACTION i]AIR HAMM lDRIVEN CASING THICKNESSTREMIE FYP) TQ$E'USED' WAUGERS 0 HOSE <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT Si l,L �� <br /> AIR SPARGEI OZONE ii PUSH POIN7(GP or CPT)GROUT SEAL PUMPED Yes Ij NO <br /> NOTE: MAXIMUM PRE£-FALL DEPTH IS 301 <br /> GROUT SPECIFICATIONS rl e�O X- �' — <br /> 601L BORING a HAND AUGER 0y U SOLTEI7 TRAFFIC BOX or p STOVE PIPE <br /> pTHER�� APPROX-BORING DEPTH <br /> ED �f_[ES' <br /> `S,!!st spedfiations in comment secJan) <br /> 07,HER: CONDUCTOR CASING PROPOS <br /> :DitiFliiEN7S: <br /> E: OFF <br /> BOR <br /> SITE INGS REQUIRE ACCESS AGREEMENT <br /> NOTOR QACHMENT PERMi�'S_ <br /> 43 KINGHOU NOTICE REQUIRED FOR INSPEcT oN <br /> hereby cern tYt t t h ve prepared this application and that the"`fork will be done in accordance with San Joaquin <br /> her y nd all applicable California State Laws <br /> :ounty Ordina s, les and +3 a <br /> TitlelCompanY <br /> Igned x r Date <br /> print Name EPARTMENT USE ONLY <br /> SITE MAP Its UNIT-IV FILE,ADDRESS_ <br /> NORK PLAN DATED; <br /> Date Issued �� j <br /> D L� prea .r.� <br /> \pplication Accepted Sy Jj Final InspeGion By <br /> 3rovtinspection By <br /> o ate <br /> Date <br /> Date <br /> )estmction Inspection BY <br /> c l <br /> ;oMMENTS t CONDITIONS= � <br /> ACCOUNTING ONLY. AID;# FACS <br /> HECK OICE <br /> RECD BY DATE PERMIT J5>:}�VICE REGlilEST INV <br /> PE CODES FEE INT1 <br /> FO AMOUNT REMiTD <br /> l <br />