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FILE COPY <br /> sae. °oa San JoaquinaCounty, <br /> Environmental:Health Department k L0 SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton CA 95202y <br /> w\I� "TIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: wwwsjgov.org/ehd \N c0 � <br /> °fcr say\o- . SPNNo tN� MENUNIT IV <br /> Well Permit Application ��NOEP <br /> NON-REFUNDABLE PERMIT EXPIRES A YEAR FROM DATE ISSUED N - <br /> 0 N }: <br /> (x Application is hereby made to San Joaquin County for a per toconstruct 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 qa n Joaquin County Environmental Health Department. <br /> a Assessors <br /> WELL.Location F-:VTe- VkAC"f Cross Street '%VC-q-1+CityI .Zip Parcel# 14-1 -Z19-0-4 <br /> I PROPE . IAC. 1�"�4 r C� t <br /> c Owner l\ S-M( tAkp r2Address 4"'261 Lv\�erl�rvSe- rra�City TYG=1Mn� Zip �'S jb Phone# f r'J� Spo - <br /> �— Cy7- <br /> C-57 Contracto�yl,r(Sg1--� _ ',I LtA kjX dress3 ZC�YIne�Grde_ Cita. U6L Zipai574ZUc#i 17510 phonel(g lb��y7�'11(a9 <br /> Consultant/Sub�ID��n Vl WIGPL'�O.AddreS,4q]O wpjy }'NR."5- City1Rbog 4Lcc#gaf53o1 Phone# 11 -71-rD <br /> GIS Coordinates:X Y "` -,Township . Range i Section <br /> WORK TO BE PERFORMED: - <br /> NEW WELL/ BORING .(CPT,GEOPROBE,HYDROPUNCH'HAND-AUGER,OTHER`) p DESTRUCTION (choose type below) ' <br /> SOIL BORING# „ 1, 0 OVER-BORE. DIAMETER <br /> '- `WELL# MW-7 s - a PRESSURE GROUT <br /> .Q Other - f * • GROUT SPECIFICATIONS !. I <br /> COMMENTS: <br /> � ,TYPE OF WELL - INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ,rI <br /> / <br /> MONITORING VHOLLOWSTEM DIA OF BOREHOLE <br /> s /-�Kjj!_ pMULTIPLE CASINGS E MULTI-LEVEL WELL CASING DIA'_2-__vl(�., <br /> Q EXT <br /> RACTION a AIR HAMMER/DRIVEN CASING THICKNESSS(.�4 TYPE OF CASING:. a STEEL PVC n.OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL S TRE1 TYPE TO BE USED: XAUGERS a HOSE <br /> a AIR SPARGE/OZONE a PUSH POINT(GP or CPT)GROUT SEAL'PUMPED:4Ye NOTE: MAXIMUMFREE-FALL DEPTH IS 30') <br /> p SOIL BORING p HAND AUGER GROUT SPECIFICATIONS 19eaA pL nnewt <br /> a OTHER: OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 'CONDUCTOR`CASING PROPOSED Llor <br /> (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 Ordi as and Regulations,and all applicable Californ" Sta aws. <br /> s ,mm /t7n <br /> Signed x s ` Title/Company Iv �t V )r� GNV(Y v'�"^••�U�Q (� . <br /> Name 4 6." a`7 �0 Date <br /> -7- <br /> Print 0 <br /> DEPARTMENT USE ONLY « „ <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 27-;?5 <br /> i <br /> WORK PLAN DATED: Z LsoS <br /> - o- o6A5' <br /> y Application Accepted By Date Issued 66 -Are <br /> f Grout Inspection By .Date ++` Final Inspection By �L a� <br /> � araate ' 6 <br /> Destruction Inspection By Datej - - <br /> COMMENTS/CONDITIONS: <br /> j ACCOUNTING ONLY: AID# FAC# <br /> I! PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC=WAIVER_. . C-57.Letter,of.Authorization to sign permit_Encroachment doc AW --•- <br /> i <br /> EHD 29-02-001 <br /> 6/22/04 <br />