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AUG-24-2004 TUE 04: 15 PH `LTE & ASSOCIATES FAX A �N6�2� �� P. 02 <br /> San Joaquin County W l� LS ORIGINAL <br /> 1 ` Environmental Health Departmel#G 2 6 2004 SITE <br /> 304 East Weber Avenue.3rd Floor,Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web:www.9i0Wj*W6 kNT HEALTH UNIT IV <br /> Well Permit Application P'79MIT/SERVICES <br /> NONREFUNDABLE PERMIT EXPIRES S YEAR FROM DATE ISSUED <br /> Application Is hereby made M San Joaquin County for a permit to construct and/or Install the work described. Tttls application is made N ownpllsnoo with San <br /> Joaquin County Dwakvdmenl Title,Cliapter 9-1110.9 mid aro Standards o7 aan Joaquin County Envkonrncntal Hcolth Doporunor,L <br /> WELLLocation 312$00. Assessors <br /> N• Or6ettdi4. R0. Crosseveel ckl6eatlhPtD Cty SratYAN ZipTaZIS PeroeliV eOT'Os'L8 <br /> PROPOM <br /> 0wnor.. ARL AfNNAv\Na Addrou 641.5 CNeWKe'a� Lily .��Ko.. Zlp'tss.t5 F'InneN Cso7) 161- Ss`7'f <br /> C-57Conbador%ft" .rt i><%oRFTIorJ Jlddrose Zbres wlo-Wrrµ RD. Cay&yarkibu Tip 957.eS Lk/'6�>L Pham+►C1ast14t.s-eTli�, <br /> ConnrlMnt l Rrrh rxW address .. ., CRY U'A ..._PhonoaM <br /> Gta CcoMlnaWs:X .Y = Tawnahlp �-►J Ranec -1 E Qaailon 1.'2- C <br /> WORK TO BE PERFORMED: <br /> >qAE'W WELL I SORINO IcrT,DEOPROME,HYDROPUNCH.HMO-AUBER,OTf " 0 DESTRUCrnON (ohaw•"baw4 < <br /> D SOIL BORING# 0 OVER-BORE. DIAME RIR _ <br /> WOrlELL N WZ i MYdaS 11 PRESSURE GROUT <br /> D' GROUT SPFCIFTCATIONS <br /> COMMENTS: G <br /> t <br /> TYPE OF WGLL INSTALLATIOY 7YpP S`.ON11'TRlICT10N SPEr*1CA'1'1frNe <br /> �WMOMI'ORING -JI1I01-LOW STEM DIA OF BOREHOLE t2:ln.0 MULTIPLE CASINGS 0 mm-n-LEVEL WELL CASING DIA-.4-.k,- <br /> EXTRACTION <br /> IA- •.- <br /> EXTRACTION 0 AIR HAMMER/DRNEN CASING THICKNESS SAN 4e TYPE OF CASING: n STEEL 'j?�VC D OTHER: 1 <br /> VAPOR D MUD ROTARY DEPTH OF GROUT SEAL70•101 F7. TREMIE TYPE TO BE USED: 9AUGERB 0 HOSE <br /> D AIR SPAROEI OZONE D PUSH POINT(OP or CPT)GROUT SEAL PUMPED: ''Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH 18 30') <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS NGAT C EMG <br /> D OTHEIRU OTHER APPROX.aUNIN(.i"V IH 1m- t7ot r T D BOLTED TWIFFIC BOX or OTOVE PIP@ <br /> CONOUOTOR OARING PROPODCD � D (If YES,IW opooalooeona in commont wadon) <br /> COMML'NTGi <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby Corti that I have prepared this applicaLlorh euid that the work will be done In accordance with ban Joaquin <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed TVI..r la�,y.� t.-eQ �J TIWCompan ) t�1-11[1 A►dse rnies <br /> Pr1nt Name F-I�C�IrICC r,r.�e_dyQN Dale A4L45T 2'1t 2001 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: —�1r-D Q – (�!/Q 467.a-z— J <br /> WORK PI AN DATED: <br /> Application Accepted By Deh 1 ^d Area Ute- <br /> GrwA In"cuon BY oto rinal mope pel,r J 2 X65 <br /> Destruction Inapectlon By Dale <br /> tiOMMCKTalcONOR7DNa: <br /> ACCOUNTING ONLY: AICHI FACE <br /> PE CODES I FF.F.INFn AMOIINT RFMrrTED CHECK a RECD BY DATE R I SERVICE REOU S Ufv%RCE <br /> M W SRO <br /> 057_ WC--WAIVER— G-57 Letter at Authorization to sign permitT Encroarhrnent clc__ <br /> �at <br /> SC: /SL <br />