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"Jq7T5770P3_ 07 38 <br /> 2094683433 FIFTH FLOOP PAGE 02 <br /> WELL PERMIT APPUC 1 N FO M SITE <br /> I' - <br /> '" r SAN JOAQUIN COUNTY MITIGATION <br /> APR ¢ 20Q3 ENVIRONMENTAL" HEALTH DEPARTMENT (EHD) UNtT IV <br /> ENNIRONIVIEP1 i NEALTH 304 E_Weber, Third Floor, Stockton, CA., 95202 <br /> PERMITiSER0CES (209) 468.3449 Off MJb C[)S <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or tnstall the work described This application is made in Comptrance Meth San <br /> JOaq-n County Development Title Chapter 1-1115 3 anCthe Standards of San Joaquin County Environmental Hearth Department <br /> e.� Assessors <br /> WELL Location.(2fa C• I�ucw4ar LK -Cross Stre9 Qs'_-a. r._-citty- J'cwGC{•0.a Zip Pmrce'!s <br /> PROpEiZry Owner C.1+-� �� address N to a city Zip <br /> ap3 <br /> C-57 Corttracto t�GL7, r " Address 6 <br /> Cit�LtCa--Zip"Llca, IA441P h 0 n e<*-k)k1L_-3_'5V) <br /> -3'i ) <br /> Consultant/Sub Cnt ( i0r1r4++ ACdres pp <br /> �Gtf� . � }f +ty �fff lade � c� PhOneM 4 Z <br /> GIsCoordriatos 0 2jQ 4 0 41!KY 17,(.m 15eW Township } RangeSection <br /> � 11 <br /> WORK TO RE PERFORMED <br /> D NEW WELL I BORING(CPT GEOPROBE RYDROPUNCH HAND-AUGER OTKER`) DESTRUCTION(choose type t:eiow) <br /> 0 SOIL BORING it OVEr2-8ARE <br /> 0 VV= <br /> LL# 0 PRESSURE GROUT <br /> 'Other Grout 5pecdtcatons <br /> COM€v)ENTS'dr; <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Mt <br /> MONITORING OLLOW STEM DIA OF BORSHOLE- MULTIPLE CASINGEIt <br /> 1 a MULTI LEVEL,D WELL CASING DIA Z. <br /> r0 EX"ORACTION 0 AIR HAMMERIORIVEN CASING THICKN=SS5r4`f0 TYPE OP CASING 0 STEEL PVC D OTHER <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �— TR=M1=TYPE TO 8E USED 0 AUGERS 0 FOSE <br /> 0 AIR SPARGE 1 Ozone D PUSH POINT GROUT SEAL PUMPEDes No (NOTE MAXIMU F E,E, --FAff LL EPTH IS 0') <br /> 0 SOIL BORING 0 NANO AUGER GROUT SPECIFICATIO ri- ii <br /> 0 OTHER 0 OTHER APPROX BORING DEPTN <br /> �-� (it YES I sl spec rcal ons he e) <br /> 'COMMENTS 2r.V 04 M� f- <br /> NIL <br /> NOTE- OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify t t have prepared,ttrm application arsd that the work will be done In accordance with Sari Joaquin <br /> County Ordtn C S, ides and Regulations, and all applicable California State Laws <br /> S geed r Ti1le/Company n Qtth er h -0-7 -j <br /> Print Name_ ]f t,r , - - Da'e 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS. 12`1 C) Cl4A,_ <br /> WORK PLAN DATED' �S- � I -O 3 <br /> Apol+cation ACceoled ay Date Issued Area d <br /> Grout InSpeciLon By Date Final Inspeatron Uy260 Date <br /> Destruction tnspec'ion By Date <br /> COMMENTS I CONDITIONS %hil=475i6 <br /> ACCOUNTING ONLY AIDra <br /> PE CODES FEE INFO AMOUNT R5M TIED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST 0 INVOICE <br /> 3502 D bb� ���3 -z�o3SRNQQ �b <br /> C- 7� WC`-WAIVER_ C-57 Letter cf Atrthorrzaticin tosign pertrtit�Encroachment doc� 8/29/02 <br />