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59/16/2905 11131 2894683432 EHD PAGE 03 <br /> EIDD WELL PERMIT APPLICATION FORM SITE <br /> SEP - 9 2005 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONh".ENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ' PERMIT/SERVICES 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (208) 468-3449 <br /> NON-REFUNDABLE PERMCT_EXPIRES I YEAR FROM DATE ISSUED <br /> ' Applidetion la hereby made to San Jaaquln Cauntyfor s peril to wI1sWG andlor inatad the work described. This application is made In wmpllar"with San <br /> Joaquin County Development Tltla,Chapter S-1916.3 and the Standards of San Joaquin County EnAronmantal Haalth Department. <br /> Assessor <br /> r+ <br /> WELL Laeatlon.25R 7 //&1,,;4"4 S `Sr.. Ord"Stmey*e wrte clry ,4,Ozlp_��Yf7PeroelM�a'YZ <br /> PROPERTYOwner ry C. N k4r.47a/S Address s.?s//ir�4y.s ._,_plry / zap4UV;PPhondl3`'�' 3Y.Z <br /> ' C-67Conwetor S/ Address=A & Gaal f9'' <br /> Ym <br /> Conaukantl Sub Con7acNr✓raaaa /4ss E"nr✓. Andress. 'Pfi1i �p,w�EY.CIryi�'LIctt9"3 Phones SC�d�a i.3 <br /> ' 00 Coordinates:X .Y .Township Range $action <br /> W R TO BE PERFORMED. <br /> E m/BORING(CPT,GEOPROBE,HYDROPUNCH,LAND-AUGER,OTHER') O DESTRUCTION(dwcoo We below) <br /> (SOIL BORING ii 1 COVER-BORE <br /> a WELL 0 0 PRESSURE GROUT <br /> 'Other; Grout SpeaFleabonse <br /> COMMENTS: <br /> ' TYPFy P WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA OF BOREHOLE_MULTIPLE CASINGS?0 YES .ONO WELL CASING DIA�/I <br /> ' aEXTRA.CTION a AIRHAMMER/DRNEN CA$INGTHICKNESS A-14 _TYPEOFCASING: DSTEEL OPVC OOTHER_ 4 <br /> D VAPOR a MUD ROTARY DEPTH OF GROUT SSAL T/�^SV 0Z(TREMIETYPE TO BE VSED: GAUGERS ¢DOSE <br /> 0 AIR SPARGE "TUSH POINT GROUT SEAL PUMPED: ,WYes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: C O'3 f G <br /> t 00THER: II OTHER_ APPROX.BORING OEP"fHL7 0 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? A10 (if YES,list speclnuffons here} <br /> •COMMENTS: Pn�- :tin N7 Y)r '��S <br /> ' NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 applicable California State Laws. <br /> ' ""no,z�!'� `� � TibelCompany. Geo A41,se G'Mdfre N ­-e -H <br /> Print Name }Tee' / N 4► Date Q�7 �d <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE ADDRESS: <br /> WORK PLAN DATED: // f��n �V 5'A / <br /> Application Aecepme!By Ld'T'G+ Data lasuad q��f.. /bs Area <br /> Grout Inspection By Date Final Inspection By CCC""" Date <br /> Destruction Ins action By Date <br /> ' COMMENTS ICONDRIONS• P W V <br /> ACCOUNTIN00NLY: AID# Kerr <br /> ' PE CODES FEEINFO AMOUNTRP-MrrTED CHEEK0 RECO BY DATE PERMrT/SERVICE RECIUMS INVOICE <br /> 9-90( 19 <br /> " �,v 4 1 safe oa�34Si— <br /> C-57_ WCC WASVER_ C-57 Letter of Authorization to sign permit—Encroachment doc_„ 1/25/02 <br />