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07/21/2005 10: 55 2094__J433 EHD PAGE 02 <br /> San Joaquin County <br /> ° Environmental Health Department SITE <br /> a 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 �(TIGATION <br /> • (209)468-3449 Fax: (209)468-3433 web:www.sjgu, <br /> oA5/e� 20 Q���' UGUNIT IV <br /> IpR Well Permit Application saK �a:u":(Ik co <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEfCNL�IR0NP AR TRENT <br /> JA <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or install the work des 7ttiapplication is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Star1td S oaal County Environmental Heslth Departmen�t.7"- <br /> $t�U4 t/CSWA Rd. ma*lz -25 /� [ '�� Q5Z'- es ors <br /> WELL Location �AILi�dAlC�;r,�t=scu IIftC1tC0.Y _ tlQet�C City -t /7�Zip `cl/ arcel# O� —OIO—OI <br /> PROPERTY Ypp6 Zip'1S6y�Phone# a0 '51�I <br /> owner F--A3'S4J MUD address 61000 CANNA PCHK IIID City <br /> weYr <br /> Cb7ContractorT �A114�L1741)T$ Address RgJ1 k/0M C�v�/�WF Cib�s M�^ozipQS69J Lic*Ill"".0Phone#L9jj)3j - 1—A'o <br /> 6tQTY <br /> 3ffio <br /> Consultant I Sub Cntr Fu60G WX&T', rMe. Address lOW SM42>2Ay CityO.nKIA,vo Lic# Phone#.C510a6b-0tl(o) <br /> GIS Coordina�- .Y ,Township Range Section <br /> WORK To BE PERFORMED: <br /> ANEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) D DESTRUCTION (choose type below) <br /> D SOIL BORING# D OVER-BORE. DIAMETER <br /> 1 WELL# So�8 (a 8 I� D PRESSURE GROUT <br /> D•Other GROUT SPECIFICATIONS <br /> COMMENTS:"r';"K% �056)1h RI oo(MREP/VC.limPr'E2U?�J141C� <br /> TYPE OF WEI,L INSTALLATION TYPE CONSTRUCTION SPECIFFCATION$ /! <br /> ,R,}AONITORING D HOLLOW STEM DIA.OF BOREHOLE-(,j!- D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: C <br /> D EXTRACTION D AIR HAMMER/ORIVEN CASING THICKNESS Qom,TYPE OF CASING• D STEEL J PVC D OTHER <br /> D VAPOR 1 MUD ROTARY DEPTH OF GROUT SEAL T5i 15� TREMIE TYPE TO BE USED. D AUGERS 1 HOSE J <br /> D AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 1 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH ISC 00 ) <br /> D SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS �`1�r1 AAII)CEI�Eh7r y 4 1A)<- <br /> OTHER'PIC�1YT1efFR5D OTHER APPROX.BORING DEPTH IQ��33 1 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASIN PROPOSED — f YES,list specificallons in comment section) <br /> COMMENTS: Q h1J.��55F �T X71?YQd��35� y 6 �4y70 ��15'SF� <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 application and that the work will be done in accordance with San Joaquin <br /> County Orclinances, les armed Regulations,and all applicable California State Laws. <br /> + (f , <br /> n <br /> Signsd x_ ',�"� �� Title/Company <br /> L <br /> r <br /> Print Name e-o,-,c �!1 •J - J,t III—r. — Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: C7 <br /> Application Accepted By Date Issued ! / J Ar., <br /> Grout Inspection By rna Date c5 Final Inspection By Date <br /> Deslruction Inspection By Dale <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMfT/SERVICE REQUEST# INVOICE <br /> ;4 6sR 3 -73 <br /> C-57— WC^WAIVER_ C-57 Letter of authorization to sign permit_Encroachment dOC� <br /> EHD 29-02-001 <br /> 6/'22/04 <br />