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San Joaquin County <br /> Environmental Health Departmento <br /> 304 East''Weber Avenue, 3rd Floor,Stockton,CA 95202 ECMW(G; i 1W k� <br /> (209)468-3449 Fax.(209)468-3433 Web www sigov org/ehd MAY I I ?005UNIT IV <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMEN <br /> Application is hereby made to Sen Joaquin County fora PERMIT/SERVICES <br /> Joaquin Cou q ty permit to conte and/or instal!the worts described This applkation Is made In compliance with San <br /> oaq my DevelapMM Title,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location Assessor¢ / <br /> Cross Street City� C _ ZEp�ParcellR- /7.I� bo <br /> PROPERTY b15514r a"Woovl UX- Iq <br /> Owners F. dress E.Fre v�rsn+fit r S�oc,�C�- zip q5 D5' no## i0��y� <br /> c.�W Contractor Lh SIJ41 Address Cityr 'K}LZJp Y533Lir — <br /> Consultant 1 Sub CMr &L wttncia�Idress��ccity Uc# Phone# C -L? <br /> GIS Coordinates.X Y Township Range E Section_j <br /> WORK TO BE PERFORMED_ <br /> p NEW LL I BORING (OGEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) Q DESTRUCTION (choose type below) <br /> / 5011 BORING#—S i3�7�v r <br /> Eu# .(3-7� 0 OVERBORE. DIAMETER__ <br /> t++r <br /> •Other Q PRESSURE GROUT <br /> " .� OUT SPECIFICATIONS <br /> MENTS CtA44 $v%4 �vr ",W t At <br /> TYPE OE WELL M-STALLATION 3nig g2HMUCTIONS EC FI T14NS <br /> 13 MONITORING Q HOLLOW STEM DIA.OF BOREHOLE - v II MULTIPLE CASINGS 11 MULTH_EVEI. WELL CASING DlA <br /> 1)EXTRACTION 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING <br /> ()STEEL E 1 A4 <br /> 11 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 1' <br /> H AIR SPARGE!OZONE 099 <br /> PUSH POINT(GP or CPT)GROUT SEAL PUMPED. Oas U No (NOTE: MAXIMUM FREE DA <br /> DEPTH 1$309 <br /> I <br /> t. allANDAUGER GROUT SPECIFICATIONS S,SAA�,sAA [i�* - <br /> n OTHER APPROX.BORING DEPTH L42g=Q BOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> COMMENTS- CONDUCTOR CASING PROPOSED _(If YES,Nst specifications in cornrnerd section) <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 Ordinan Rules and Regulations,and all applicable California State Laws. Ur�J q fns S('ik. <br /> Signed x V J.1 <br /> Title/Company_ ,�P/l'd _ CSI�LI.� `� ,.,. -¢-„�L-� <br /> Print Name ..�_Q- Date `5-1 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: 9 6„ •— "19 <br /> WORK PLAN DATED: > <br /> Application Accepted By Date Issued to-19—d5 Area 06 <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST II INVOICE <br /> CS7rND z�WC -WATVEtt C-57 letter of Aut dnt�t�ts'fstgn permit Encr c�t���_ v_�f ,. <br /> 9/31/2003 O / ,-"'b`sru <br />