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03/21/2805 14 01 2094683433 FIFTH FLOOR PAGE 03 <br /> 401 t � I <br /> 1_;!_-,9 ;Ij 1; - San Jaa�uin CountyWn <br /> Environme>nital Health Department SITE <br /> 1tljA? r =�3aMst'Weber Avenue, 3rd Floor,Stockton,CA 95202 MITIGATION <br /> f9 Fax (209}468-3433 Web www s�gav org/ehdren cF+{ti! UNIT IV <br /> PE �fi"iia_ ICES Well Permit Application <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to oanstruct andlor install the work described Ttris application m mad compliance with San <br /> Joaquin County Development Title,Chapter 9-1116 3 and the Standards of San Joaquur County Environmental Health Department <br /> �t _ Pssessvrs <br /> WELL Loaatton a?�3 Cout,jrrX C 1kb 6("'A Gross Street �ycPP City GiLfar� Zip 'Sa70'1' Parcel$ I 1 -z30 -of <br /> PROPEL` sao-.4 <br /> Owner �Q o.. Cu�nwT��eAddress IRIJ C-nxxd C4k 01 Riud City `�fDt toN 7,p -,407 '�— <br /> Phone#_ <br /> t CC-S7'ContMctor6►re�ti >.-At k,� --Address 24'1r Grlrr� ,4vG City�, r„olFf.tf Zip 908oG LIC#(rsrbY07Phone#3_6A 'Y,2'? kfy? <br /> r rL w w.4 0 <br /> Consultant/Sub CntrSiXOR .kj"iiop CrtyCD'doury I rC# Phone#,4/6` f6/-1x400 <br /> GIS Ceord nates X Y Township - Range Section <br /> WORK TO SE PERFORMED <br /> �51NEWEf~L/B { GEOPRO13E HYOROPUNCH STAND AUGER OTHER*) 0 DESTRUCTION (ehoosa type below) <br /> dIL SORING# 4 T- 7- r, DOVER-BORE DIAMETER <br /> WELL# ffC. 00 lcotx I 0 PRESSURE GROUT <br /> *-*other _ GROUT SPECIFICATIONS <br /> COMMS TS <br /> I <br /> TYPE OF LL INSTALLATION TYPE CONSTRUCTIPIV SPECIFICATIONS <br /> 0 MONITORING p HOLLOW STEM DIA OF BOREHOLE Z' S"[I MULTIPLE CASINGS [I MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMFRIORIVEN CASING THICKNESS TYPE OF CASING 0 STEEL p PVC [)OTHER <br /> 0 VAPOR 0 MUD ROTARY D@PTH OF GROUT SEAL-1,10 ft TREMIG TYPE TO BE USED 0 AUGERS g HOSE <br /> p AIR SPARGE!OZONE`WOUSH POINT&P r�)GROUT SEAL PUMPED A Yes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 34') <br /> ��O1LBORING � Il HANDAUGE. ��� GROUT SPECIFICATIONS_ <br /> ` (OTHE;R1% OTHER APPRQX BORING DEPTH 1 fO f>~ _0 BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> t t D" ^ro 7 f r &_r CONDUCTOR CASING PROPOSED A10 (it YES,list specifications In eornmant sectran) <br /> COMMENTS �'G � <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 be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State taws <br /> Signed x_ ; ;s� �_ _ TdiefCompany �'T�i'✓D .t r �r �`� Sr�f <br /> `- �,.., <br /> Print Name 2eL 044 d�+ �r,?yv! Dat, <br /> DEPARTMENT USE ONLY <br /> SITE MAF' IN UNIT IV FILE, ADDRESS. <br /> WORK PLAN DATED Za-� <br /> Application Accepted By Date lasued ------Area Q�y <br /> Grout Inspection By Date Final Inspection ay bate <br /> destruatlon Inspection 6y Date <br /> COMMENTS!CONDITIONS <br /> ACCOUNTING ONLY AID# FAG# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D EY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> •X57_„_.,-,,, WC____-WAIVE R-_,.. C-57 Letter of Authorization to sign permit_.,,Encr ment doc_ <br /> EHD 29-0,2-001 � �'+ �• <br /> ti=04 fr <br /> I <br />