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10/26/2004 09 50 2094683433 FIFTH FLOOR PAGE 03 <br /> E Ci <br /> WELL PERMIT AP LICA ION FARM _ <br /> MITIGATION <br /> 1L __ -= - SAN JOAQUIN COUNTY UNIT 1V <br /> OCT <br /> C 15I1/IRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 4 E. Weber, Third Floor, Stockton, CA , 95202 <br /> I1�n4rr�I'i 209) 468-3449 0 <br /> NOIR!- EFUNDABLE PERMIT FIRES 1 EAR FROM BATE ISSUED <br /> Appiycdbon s hereby made to San'Joaquln County fora permit to construe andlor install the work described This applicabon rs made rn compliance with San <br /> Joaquin County bevolopmennt!t Title,Chapter S 1115 3 and the Standards of San Joaquin County Environl/mel[n--tal Health Department Assessors <br /> WELL Location y moi• - Cross Street�^ 4.� City Zap_Rarr <br /> PRapERIYOwnerQ • Address f <br /> C-57 Contractor u ddressa0 r'W6[ AJ�_C�-ziPRSSDpp3,, Lr ? Q[�Phone# <br /> Consultant 1 Sub( ntr 11 ddress <br /> Cy Llc#+Y�ri�D�- Phone# r1 <br /> S <br /> GIs Coordinates x <br /> Y -,Township. Range Section <br /> WORK TO BF PERFORMED DESTRUCTION(choose type below) <br /> r EW WELL!BORING(CPT,GEOPR06E,HYDRO PUNCH HAND-AUGER,OTHER') (I OVER BORE <br /> -a SOIL BORINQ 0 [} PRESSURE GROUT <br /> .other Grout Specifications <br /> COMMENTS <br /> TYPE=OF WELL 1NsrAt LATION TYPE CONSTRUCTION SPECIFICATIONS w <br /> )4AwrORING A tOLLOW STEM DIA.OF BOREHOLE � MULTIPLE CASINGS7 n MULTI-LEVEL?DWELL CASING DIAZ_. <br /> [j EXTRACTION 0 AIR HA4t141>=RlC7RfVErfV CASING THICKNESS 50A �TYPE:OF CASING U STEEL APVC 007-HER <br /> HOSE <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL O TRerM1E TYPE TO BE USED A Ct <br /> n <br /> AIR SPARGE)dZOn@ p PUSH POINT GROUT SEAL PUMPED p Ye! -kNo (NOTE; MAXIMUM FREE-PALL DEPTH IW <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS,� "f " ���TEO TRAFFIC 134X or Q STAVE RIPE <br /> 0 <br /> OTHER ��OTHER APPROX BORING DEPTH <br /> CONDUCTOR CASING PROP 0SE07 1LJD (IfyrS,list specifications here) <br /> *COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTAdNS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County 0r4t , Rulse and Regulations, and all aDphuable California State Laws, i�t <br /> Signed ��� <br /> Tdla/Company A4 <br /> x <br /> —530 ©� <br /> - - — — <br /> PrintNa11e Q — DEPARTMENT USE ONLY � <br /> SM MAP IN UNIT IV FILE, <br /> WORK PLAN DATED: $ " l -d-2 " <br /> Date Issued ���� Area <br /> App[cataon Accepted By pate <br /> Grout Inbpedaon By Date Pinel Inspection By^ <br /> Destruction Inspection By pare <br /> COMMENTS!CONDITIONS <br /> ACCOUNTING ONLY AIDS <br /> PE GORES FEE INFO AMOUNTREMITTED CHECK aY REC'R BY DATE PERI4ttY SERVICE REQUEST INVOI <br /> -3501 Mv4 r o I ��-zS <br /> C_57___- WC`-WAIVER C-57 Letter of Authorlxatlon to sign permrt,�-Encroachment doc <br /> 6/29/0 <br />