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09/3012004 11 45 2094683433 FIFTH FLOOR PAGE 05 <br /> I WELL—PERMIT APPLICATION I` ,..sRM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (FHD) UNIT IV <br /> "[D 7304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> r r t <br /> ' (209) 468-3449 <br /> NON-REFUNDA13LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a permit to cons•rvct and,'or install the work descnbed Thls appllcatlan is made in compliance with San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> ja0- A3 bo AssOSSOF5 <br /> WELLLocattan 2-'360 14e&+ _G + _�-+�Cross Street_ F-kr wa�� _City �'i`aG Zip Paroe!# � S`oa' -� <br /> PROPERTY Owner ��vGfi��1 y�G Address 4 { 4Y� I City_P411A- ('2�Z!pZ5Z?-I_Phone# <br /> C-57 Cont ('; ll}n Addressq i-�owe Irl C�tyMUT�iAeZZ,p�1LlS5LIc#`�$S�6�phane# (4?-S)3t3� a0 <br /> �ot't IGI�o� R.r�, Sfie ta4�rx..r.�o <br /> Con9ultantlSubCntrSCCc?R Lic# bS—,,,,_. q Phone# <br /> s <br /> GIS Coordinates X _. .._. Y — ,TpYrnship �1 _Range F Section <br /> WORK TO BEI=O <br /> )KNEW WELLL I BORING rGPT GEdPROBE HYDROpUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL 605RING# jI OVER-BORE DIAMETER <br /> XWELL,r IKAW- - S- []PRESSURE GROUT <br /> 0*OtherGROUT SPECIFIClATIONS <br /> S60--'t-AC- <br /> _- <br /> I COMMENT . �e.a, Gt � L� <br /> AC1�ed wO�- - ,nt4n �r '^r��< <-cnson Sp r 1 CCk*;QA _ <br /> I TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 'VMONITORiNG AHOLLOW STEM DIA OF DOREHOLE__`" 0'MULTI¢LE CASINGS []MULTI-LEVEL WELL CASING DIA 2- `s' Ll <br /> EXTRACTION p AIR HAMMERIDRIVEN CASING THICKNCSS t r- 0 TYPE OF CASING []STEEL VVC []OTHER <br /> a VAPOR ]MUD ROTARY DEPTH 00 GROUT SEALA+y 2 TREMIF TYPE TO BF,USED ,ZAUGERS 0 HOSE <br /> ]]AIR SPARGEI OZONE PUSH POINT(GF'or GPT)GROUT SEAL PUMPED ©Yes )(No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING p HAND AUGER GROUT SPECIFICATIONS <br /> Q OTF5R 9 OTHrR APPROX BORING DEPTH KBOLTF.D TRAFFIC BOX or U STOVE PIPE <br /> _tl CONDUCTOR CASING PROPOSEd. (if YES list spcctfications In comment section) <br /> I COMMENTSD D1 _�„CSJ11AA _ <br /> NOTE: OFFSITE BORINGS EQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> I48 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 Ordinances, Rules and Regulations, and all applleable California State Laws r <br /> Signed xTitlelComparny P,,0*eGf aCOIo i S# $ Co h`1 nA `Onai <br /> Pnnt Ndme <br /> Date I I DN <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 2 t 40 �JnP . Lt 0- -!i'-v -� 7 - <br /> IWORK PLAN DATED' <br /> Application Accepted By G Date issued c, rea <br /> Grout lnspect�on By r�r� bate �- Final Inspection By Datr <br /> IOestruct,on Inspection ay Date <br /> COMMENTS I CONDITIONS <br /> IACCOUNTINIG ONLY AIL14 FAC# <br /> PE CODES FEE INFO AMOUNT REIOITTED CHECK# REC'D 13Y PATE PERMIT I SERVICE REQUEST# INVOICE <br /> 3SO f S�• SS66 S f SR# $ PS S— <br /> C-57— WC -WAIVER-- C-57 Letter of Authorization to sign permit— Encroachment clod 9{30/OZ <br /> I <br />