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�. RECEDED APR 1 5 2405 <br /> San Joaquin County <br /> '' SITE <br /> Environmental Health Departn� �ITIGATIO�11 <br /> toc6n CA 95202 <br /> � 304 East Weber Avenue,3rd Floor, 5 , <br /> ':• t209)468-3449 Drax: (2Q9) 468-3133 Web:w .sjgov.n ' ehd ?';fin ' UNIT IV <br /> Well Permit Applicatic n EAuV;riMV i -T!�. <br /> NOW-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISS17�f� --� <br /> Application is hereby made to San Joaquin County for a permit to construct andlor Install the work described, This application1s.made in Compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department Assessors <br /> L�. Cross Sts'eet City SAm x�(l Zip d��' ParoPi <br /> WELL.Location x� <br /> PROPERTYVo-ile i600e-C LOQ <br /> Owner Address 14t L13, � City—`�k>�cl�+o.. zlp�t�Phone a4��' -061 <br /> c-5lcontractor ( �A_C�rt111t� _AddrecitylUf�. b 7 zlp{� Lic#r}�Si{pSPnorre# <br /> asulian ISub Cntr, eQf,�ctira.�"fie 1'�rtic Address ItOI ' -54-- �`� -Ll >�hene# vq Sia y��c <br /> GIS Coordinates: ,Y Township_tsnge� — Section <br /> }jiIDR1f TO BE Pg8FQ8tY EP; <br /> g NEW WELT_l SORING (CPT,GEOPROBE,HYDROPUNCH,BAND-AUGER,'OTHER") � TRUCTION (choose type below) <br /> 11 SOIL BORING# VER-BORE...:D]AMETEaR r` <br /> RESSURE GROUT <br /> d WELL ---.._.. .._.._ GROUT SPECIPICATipNS_..._... <br /> COMMENTS: <br /> - <br /> rfM.OE WELL ii`i. TSTALLAMPtj J'.PE N5 C P C FICA"_ONS <br /> MONITORING 1]HOLLOW STEM DIA.OF BOREHOLE 1],MULTIPLE CASINGS 1]MULTILEVEL WELL CASING DIA:. _ <br /> 11 EXTRACTION 0 AIR HAMMERIDRWEN CASING THICKNESS STYPE OF CASING: "STEEL' 11 PVC 1]OTHER: <br /> C1 VAPOR q MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. GAUGERS 11 HOSE <br /> a AIR SPARGE!OZONE 11 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes I]No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 1]SOIL BORING 0 HAND AUGER GROUT speciFiCATIONS <br /> 11 OTHER: n OTHER APPROX.BORING DEPTH a BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (If YES,Iisi.specM tions In comment section) <br /> COMMENTS: Nd.I�s i - 5 � S iL- �.�.m <br /> NOTE. OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS: I <br /> I hereby certify that I have prepared this application and that the work will be Norte in accordance with San Joaquin' <br /> County Ord[ "Wations,and all applicable California State Laws.. <br /> Signed x - fitlelCcxnpanY �'iA <br /> Print Narne Date / Q� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: . <br /> WORK PLAN DATED: <br /> Application Accepted By ` pate Issued ' r ¢ �+ Area Grout Inspection 8Y C17-1, to Final Inspectlon$Y A1' - Dais <br /> Destruction Inspection BY Date y <br /> COMMENTS I CONDITIONS:. <br /> ACCOUNTING ONLY: AtD# FAC# <br /> I• <br /> PE 60t]ES FEE INFO AMOUNT REMITTED CHECK# FW01) DATE PERMIT i SERVICE REQUEST# INVOICE <br /> D 2 o Zl <br /> SF # Zco 3 <br /> C-57— WG__,--WAIVER._, C-57 Letter of Autho izat to'sign pertnit--i:neroachtnent doe <br /> F-HD 2942-001 <br /> 6/22/U <br />