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09/27/2004 13 46 2094683433 FIFTH FLOOR PAGE 02 <br /> "u. �, I <br /> San Joaquin County <br /> .� Environmental Health Department <br /> 304 East Weber Avenue,3rd door, Stockton,CA 95202 SEP 2 4 WIGATION <br /> (209)455-3444 Fax (209) 468-3433 Web www sagov org/ehgNVIRONMEN7 i�FA NIT IV <br /> Well hermit Application Mf7/SES ES <br /> NON-REFUNDABLIr PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work described This application is made In compliance with San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Haalth Department <br /> r+ Assessors: <br /> WELL.Location !~ v t a Cross Street t! lS� City tD` zip <br /> OwnerERY,M- e Q i 1 t.o_ Address R57 \A) Clty 1 Z"%1 Phone# <br /> Address a'2i 1 C-S7Gantractor-6 �fi _ � <br /> Consultant/SubCntr SVro <br /> 6�Phona4X161 B6 1-br-ft70 <br /> GIS Coordinator X Y Township 9 __ Range _Section--30 - <br /> WORK TO BE PERFORMED <br /> NEW WELL 1 BORING (CPT GEOPRQBE,HYDROPUNCH,HAND-AUGER OTHER`) I1 DESTRUCTION (choose type below) <br /> 'SOIL BORING# -,� S Q OVER-BORE DIAMETER <br /> p WELL# a PRESSURE GROUT <br /> •OtherGROUT SPECIFICATIONS <br /> COMMENTS — - — — <br /> TYPE OF WEL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> a MONITORING ,'HOLLOW STEM DIA OF BOREHOL�a muLT[PLE CASINGS p MULTI-LEVEL WELL CASING DIA <br /> 1]EXTRACTION 0 AIR HAMMER'DRIVEN CASING THICKNESS_TYPE OF CASING 1]STEEL G PVC 1]OTHER <br /> ItAPIR <br /> 0 MUD ROTAR'v DEg�],,!PTH OF GROUT SEAL &Mn J�_TREMIE TYPE TO BE USPRO ,AUGERS a HOSE <br /> SOZONE ()PUSH POINT(GP or CPT)GROUT SEAL PUMPED �1'es 0 No (NOTE, MAXIMUM FREE-FALL DEPTH IS 30') <br /> G L3ARI}VG 1]HAND AUGER GROLIT SPECIFICATIONS fn <br /> U OTHER Q pTHER APPRgX BORING DEBOLTED TRAFFIC BOX or l)STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_(if YES list specifications In comment section) <br /> COMMENTS <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 anRegulations, and all appllcable California State Laws <br /> Signed TitlelCompany &,Dlmksk SECOC, 1n �6zGtI inc. <br /> Pant Narne r Date, IZ1�17Lj <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS <br /> WORK PLAN DATED / <br /> Application Accepted By C Date Issued Area ^ <br /> ill <br /> Grout lnspeo1,on 6y _ ___Date Final Inspection 8y paw_ - — <br />' Destruction Inspection Sy Date <br /> COMMENTS 1 CONDITIONS ¢ alb <br /> u <br /> ACCOUNTING ONLY AID# _ � FAC# <br /> PE CODES FEE INFO AMOUNT P,EMITTED CHeEC�K�# REC'D BY DATE PERMIT/SERRVIICE(REQUEST# INVOICE <br /> C-57 WG -WAIVER-- C-57 Leiter of Authorization to sign perrllrt Encroachment doc, <br /> EHD 29-02 401 <br /> 6'22'04 <br />