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05/04/2004 14 17 2094683433 FIFTH FLOOR ; Pf�GE2 <br /> .� C, <br /> WELL PERAWT APPLICA 1 ON "FORM SITE <br /> 2444 SAN ,IOA,QU>TN COUNTY MITIGATION <br /> 3 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> tN ocoNO 304 E Weber, Third Floor, Stockton, CA , 95202 UNIT IV <br /> aA� ��NtNEt xL (209) 468-3449 <br /> �t�O�pA N1 <br /> NON REP UNDALB LI_PERMIT EXPIRES 7 YEAR FF@pM bATE i5SUED <br /> Aaplrcation Is hereby made to San Joaquin County ror a porm,t to construct anwor irstell 1ho work described This application is made,n compiienoe w;th San <br /> Jraaqun County Development T Ile Chapter 9-11,15 3 and the S`andards of San Joaquin County Environmental Health Department <br /> �GD �. Assessors <br /> WELL LoCafrnR 1 <br /> !� LtL4l � Cross StrEet '- S City <br /> PROPERTYihh''��rr� �j 7 (� <br /> Owner, 4-- t� -Z T Address fSZ Cid 11-V LKS �Pwt 4jjyL �I feZip 1�3 <br /> C-57 Contractor VP �I[i7 Ad�r�g5`I>(� / -urG 44 C,ty(�+�cfl�dlZZ Ziff L7 #q?5f6 Phone#[512 sr�-- <br /> consultant I sub Cntr - / 30 LtLyl <br /> ` Adtlress <br /> GIS Coordinates X Y� � Township Range �� Section 71T <br /> W I� To BE PDkFORMED <br /> jt NEW WELL 10 0 RING (CPT GEOPROgE LyDROPUNCH HAND AUGER OTHER') p DESTRUCTION (choosetype below) <br /> 0 solL BORING# <br /> OtnerTKNELL# j 0 OVER-BORE DIAMETER <br /> 0 PRESSURE G0OUT <br /> COMMENTS GROUT SPECIFtCATlbNs <br /> TYP1...� PF WELLINSTALLATION TYPE CONSTRUCTION SPECIFICAVONS <br /> MONITORING HOLLOW STEM DIA OF BOREHOLE `� 0 MULTIPLE CASINGS a MULTI LEVEL WILL CASING DIA�►r - <br /> 0 EXTRACTION a AIF HAMMER/DRIVEN CASING Tr�ICKNE85 51ck Lt0 TYPE"OF CASING 0 STEEL XP_VC Q OTHER _4 <br /> D VAPOR I)MUD ROTARY DEPTH OF GROUT SEZITREMIE TYPE TO BE USED XAUGERS 0 HOSE <br /> U AIR SPARC,EI O_ONE 0 PUSH PAINT(GP or CPT)GROUT SEAL,PUMPED 0 Ye9Jfkiyvo (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING p HAND AUGER GROUT SPECIFICATONS. 1 -AST <br /> (I OTHER _ 0 OTHER APPROX BORING DEPTH_ f7 f 5 —',dgOLTE0 TRAFFIC 80X or 0 STOVE PIPE <br /> COMMENTS <br /> CONDUCTOR CASING PROPOSED (O �^ (ITYES,list specifications in comment seabon) 1 <br /> w <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 applicetlon and that tho work will be done In accordance with San Joaquin <br /> County Or rices, Rules d Regulations, and all applicable California State Laws L p- <br /> Signed K )E 61 Tit1elCornpany , <br /> IILre� ,fit <br /> Print Name <br /> Rata <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS <br /> WORD FLAN DATED'� t6.3 c� <br /> Appllcatlan Accepted By C _ _Date Issued 5 z{ Area f 7 y <br /> Grout Inspection 3y r Date Fcnal Inspection By__ L3ab <br /> Destruction In pactlon By Date -- <br /> COMMENTS/CONDITIONS <br /> ACCOUNTING ONLY AID# FACt <br /> PE CODES DEE INFO AMOUNT REMITTED CHECK# I REC'D SY DATE ESERMIT'SERVICE REQUEST INVOICE <br /> 56 s- <br /> C-57 WCC WAIVER_ C-57 Letter of At!$l;arizatlar ;c sign permit—Encroachment doc_ 9/30/02 <br />