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San Joaquin County <br /> Environmental Health DepaICENEDMMIGAMN <br /> SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockto ` <br /> ' (209)468-3449 Fax:(209)468-3433 Web: www.sjgo jAyV td4 <br /> 2010 <br /> UNIT IV <br /> Well Permit AppileationENVIRONMENTHEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DNIft�yp�f7 I(`C� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. SE epbhclaAdn is made in compliance with San <br /> Joaquin County Developmen TMe,Chapter&1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> $ "4 5. 14vta.1 94.) to4ie W Asseuors <br /> WELLLocation �,,l_. /,(ty-Cr, I!!StreetT J�'Y� City �'+�„✓a� Zip�(533d Parcel# �nP <br /> PROPERTY �l <br /> Owner CI Address ()T WV4 (6n�/{ D1, Cry Zipg53'Yl Phohe#j� -9�1- /y� <br /> CST ContractorR r t nu hr Address ZOO P, 11-)4 5�. City Lkg!rl�4wd ZpI07( Uc#?01334 Phone#r s?a-tGy-2424 <br /> Consultant/Sub Cntr 5'I SFnv1 T'"fV"d 330 t ,nf/on Dn,� �!��$ty Catry�FL,,* Z Phoma# ./3d-G7(a-�((�Z/ <br /> GIS Coordinates:X_,Y ,Township Range Section rn <br /> WORK TO BE PERFORMED, <br /> D NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> g SOIL BORING# ,t <br /> g OVER-BORE. DIAMETER <br /> ' DWELL# - �'fRESSURE GROUT - <br /> D`Other /� M GROUT SPECIFICATIONS (LWj- <br /> COMMENTS: MU)-I'l,AIlli /'ik/-I5 Ml m�-I�f��. MW-J`//j <br /> r <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS I <br /> D MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_ 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: g STEEL D PVC g OTHER: <br /> g VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS D HOSE i <br /> 'D AIR SPARGE1 OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS <br /> . 0 OTHER: n OTHER APPROX.BORING DEPTH g BOLTED TRAFFIC BOX or D STOVE PIPE ' <br /> CONDUCTOR CASING PROPOSED (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 /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County O•,71`Ma�nClc� las and Regulations,and all applicable California Stta�te Laws. <br /> Signed x ll.lV1/�� �/ 7itle/Company cxfj('5A+- 54. <br /> .Print NameS(6A l-lAy(n Date �2-2I-0y <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 S4 O O Hr6A (G1 <br /> i <br /> WORK PLAN DATED: N/A- <br /> 'Application Accepted By (A-'li,�f e-, Date Issued <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By - Date f 7 to(0 f <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEEINFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUESTS INVOICE <br /> 3S02 `t�S�oc� z-k--CI ( Ctk 1 2-1i2 ro SR# S ) 33 5 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permits Encroachment doc_ <br /> EHD 29-02-001 <br /> 6/22/04 <br />