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AIJG-24-2004 TUE 0415 PM NW & ASSOCIATES FAX N0, 0641 9222 P. 02 <br /> ' F__ > "E;, /,QLD FILE COPY <br /> i �i U �� <br /> Gl j� San Joaquin County - SITE <br /> z• �� <br /> Environmental Health 1)epartmqX4G 2 6 2004 <br /> v < 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.siA6VLo'r.�1e)td�! N NLl H UNIT IV <br /> cl.�;.r,!T!SE9VICES <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install ills work described. This application is made in compliance will)San <br /> Joaquin County Developnront Title,Cliapter 9-1115.9 and the Gtandardn <br /> a of can Joaquin County Enviromental Hcalth DopartmontAssessors <br /> ti0, Cil +•IRLY:t W Zip W?'t5 Parcel# OS 7-os.'!-/`o <br /> WELL Locatlon3 ON• o��� RD. Crass Street c.tE'ebyee y <br /> PROPERTY Address 6Vs tHenErt2L -OnymLr Kw ?Ip9TL' Phone#_[�"t) <br /> OwneuamlY &ANWOAND ^ q31- 35'7'1 <br /> 7.'a.Gb Phone#Lzewl Uiy-&71a- <br /> 057 Contractor 5Fi`sTauH ErPt>u-F ro4Address 23fn5 W IGWANt RD. City STerKTau Zip 9s4oS Llc#51 <br /> Consuhnnf lRnh Cnir = Address ^ .. .. <br /> City — Lic# ` ..-_Phone# <br /> To.nahlp <br /> 2.AI Rongc --71C 6octlonI.�� <br /> GIS Coordlnatsu:X ,Y----' <br /> WORK TO BL PERFORMED: <br /> >ji IEW WELL 160KINO tCPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION ETER o type below <br /> Imo_ ()OVERBORE. DIAMETER <br /> D SOIL BORING# - d PRESSURE GROUT <br /> KNELL# L-�t`Ix- N W�' GROUT SPECIFICATIONS <br /> 11`Other• <br /> COMMENTS: <br /> TYPE OF WELL INSTALIJ llirIN TYPE MNRTRlICT10N SPEr•IFIM <br /> -$MONITORING -;VOLLOW STEM DIA.OF BOREHOLE 1Z%A.O MULTIPLE CASINGS 0 MULTI-LEVEL,RWELL CASING DIA: <br /> 1 EXTRACTION 0 AIR ROTA R/DRIVEN CASING THICKNESS $19 DEPTH OF GROUT SEAL'7o 40TYPE <br /> i TYPE TRCASING:YP 0 STEEL USED: <br /> gA GERSR 0 HOSE <br /> L VAPOR 0 MUD ROTARY <br /> 0 AIR SPARGE!OZONE p PUSH POINT(GP or CPT)GRCUT SEAL <br /> SPECIFICATIONS J �eII 0 NEacNOi E: MAXIMUM FREE-FALL DEPTH IS 301) <br /> p SOIL BORING 0 HAND AUGER <br /> OTHER APPHUX.BURING Uht'1 H Irn %% T�0 BOLTED TRAFFIC BOX or TOV2 PIP <br /> 0 OTHER: 0 CONDUCTOR CAGING PROPOGCD 11 0 (If YES,Iia/apecificollono in comment cootlon) <br /> COMMENTS: <br /> AGREEMENT OR ENCROACHMENT PERMITS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREE <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> 1 hereby Certify that 1 have prepared this apPlicatiull alld that tine work will be done in accordance with Sen Joaquin <br /> County Ordinance-, Rules and Regulations,and all applicable California State Laws, <br /> i an til TklelCompany gNc�ttgge� tx LTG AbsscrnTrS <br /> Signed x 1 V'L.r 6y5 1 — 2rl 2m�1 r- <br /> Date <br /> PrinlName NuH � n"mss°"' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PI AN DATED: Ave <br /> Date Issued Area <br /> Application Accepted 8y -., ,M at <br /> Grovt Inspection By Dale _Flnol Inspscdon B a �-• •" " <br /> Destruction InspecAon By Dale <br /> L;UMMENT5 1 CONDITIONS: '- <br /> ACCOUNTING ONLY: AID# FACN .. . <br /> PE CODES FF.F.INFn AMOUNT RF.MrrTEO CHECK# REC'D BY DATE PERMIT 1 SERVICE RE/4UEST# INVOICE <br /> l �7 SR# 7 <br /> C-57_ Wt _-WAIVER_ C-57 Letter of Authorization to sign permit—Encroachment d c— p�- <br /> tHu 29-02•051 /n . fe. <br />