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12/07/2005 16 32 2094683433 EHD PAGE 02 <br /> o g r San Joaquin County �!~ <br /> I-J.1 <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 9c _ 7 MITIGATION <br /> (209)468-3449 Fax (209)468-3433 Web www sego i or�/ehd <br /> UNIT IV <br /> rf'J.1F{Jt'14r,E <br /> Well Permit Application p�;r�!f'�L��; ,�Pr1!_ry <br /> tl <br /> NON�FUNDASLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I r-S <br /> Application w hereby made to San Joaquin County for a permit to construct and/or install the work described This application is made In compllanoe with San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Ern,ronmental Health Department <br /> Wmt WELL Location 5 �+er~1 D , Cross St `City iJz,pTi2&Prce ,d_R <br /> PROPERTY <br /> Owner Address rA:sn City � 1 iA l 'hone r 3 b-y <br /> C-57 Contractor 1f� ` Address 11�t�rr City tYYI �tc# 6 one# 3 i - Zoo <br /> Consul t!SubCntr v.r sr� Address ISL � Clty�r LIc*— Phony# `!4' 4 70 -O�ec> <br /> GIS Coordinates X Y Township flange Section <br /> R1 TO BE PERFORlNED <br /> EW WELL I BORING CPT,GEOPROBE HYDROPLINCH HAND AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> Ain- <br /> OIL BORING# Q OVER-BORE OIAMF-T]= <br /> LL* 11 PRESSURE GROUT <br /> Other GROUT SPECIFICATIONS <br /> COMMENTS_ '\ A. 3 c <br /> TYPE OF WE <br /> LL INSTALLAMON TYPE GONSTRU 9N SPECIFICATIONS f <br /> ONffORiNG % iOLLdVtf 5 f�M OIA OF BOREHbIE� MULTIPLE CASINGS JJ MULTI-LEVEL WELL CASING DIA <br /> II EXTRACTION d A_IR HAMMER/DRIVEN CASING THICKNESd L05CK 440TYPE OF CASING 13 STEEL VC <br /> Q OTHER <br /> A VAPOR 0 MUD ROTARY DEPTH OF GROUT I TREMIE TYPE TO BE U ED 'UGER$ f]HOSE <br />�(�A PARGEJOZONE p PUSH POINT(GP or CP SEAL PUMPED es o {NOTE MAXIMUM FREE-FALL DEPTH IS 30'} <br /> ORING 12 HAND AUGER GROUT SPECIFICATIO <br /> O EFifl OTHER APPROX BORING DEPTH — c) 6 46CLTED TRAFFIC OX or U STOVE PIPE <br /> CED ONDUCTOR CASING PROPOS !7 <br /> COMMENTS (If YES fist specifications in Comment se00n) <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 /> Count1101rdi antes, Rule$$ d egul its,and all applicable California State Laws <br /> Signed x TiyelCornpany 0 Print NaDate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: pp�� �{ <br /> 4pplicatlon Accepted By `7 Date Issued L� ZOO Area <br /> 3rout Inspection By Dale - / Final Inspection By <br />]esruchon Inspection By Date <br />'.OMMENTS!CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REVD S DATE PERROT!SERVICE.AEQUE5T# INVOICE <br /> 0 21 Go sR# Jrrl <br />:-IW— WC -WATVEA`_ G-57 L.eYter of AuYh z la o sign perrnri�Encroachment doe <br /> EHU 29-62.001 <br /> Sr22/fla <br />