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05/02/2007 WED 16: 43 FAX 2094683433 SSC EHD 002/002 <br /> 04/28/2007 11:51 916-786-0366 LFR PAGE 02/03 <br /> 04/30/2007 MON 10!57 FAX 2094683433 SJC ego 0003/DD3 <br /> ' 0 San Joaquin County <br /> w; Environmental Health Department SITE <br /> 30413ast Weber Avenue,3rd Flop,Stockton,CA 95202 MITIGATION <br /> ' (2091468-3449 Fax:(209)468-3433 Web:www.Sjgov.orgyehd UNIT IV <br /> Well Permit Application <br /> NgN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 18SUED <br /> Application is hereby made to Sen Joaquin County for a permit to conslmel andlor install the work described. Thls appOcallon is made In compliance with San <br /> Joaquln County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELLLOWTon Z?X99..5/fly.00�Bt+I iZ ,'o�ca-st�etC�%�G�ly sS"city p rp q ar�la�-Y5'>12-c�'�� <br /> PROPERTY rrT/G - � Address 9�� +�,�/5t:'lel7r Cf ,� 2Ita 3�&fte8 6 e^z . <br /> C-59 Contractor_WD G FX�ddress f51-4V C�.��fl sd +rN�-zlp4 kn 33?fioneny.a© lor�02' T"8i <br /> . ConsutfantlSubCntr LFl-r I/✓G Addmis%(1� lS Clly wF r Icir phone#9s a• •43� <br /> 018 Coordlnales:X Y ,Township Range Section <br /> ' WORK TO BE PERFORMED: <br /> R NEW WELL 1 BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGC-R,OTHER? )MCIESTRUCTION (choose type below) <br /> U SOtL BORING N n OVER•BCRE. DIAMETER <br /> 0WE:LLa RESSUREGROUT " <br /> a'Omor YOROUTSPECIFICATIONS <br /> COMMENTS:,_-,d��'KTM� IYILtJ S � F <br /> TYPEOFWELL INSTALLAt NTYPO CONSTRUCTION SPECIFICATIONS b <br /> XMONITORING RHOLLOWSTEM DIA.OFSOREHOLE_ n MULTIPLE CASINGSRMUL71-LEVEL wELLOASINGDIA:___ <br /> ' aEXTRACTION O AIR HAMIMERIDRIVEN CA6ING THICKNESS TY,PEOFCASING: USTEEL ORVC nOTHFR; <br /> UVAPOR 0MUD'ROTARY DEPTH OF GROUT SEAL TREMIETYPETOWUSED: GAUGERS 1]HOSE <br /> a AIR SPARGElOZONE OPUSH POINT(GP orCPT)GROUTSEAL PUMPEO: OYes ONo (NOTE:MAXIMUM FREE•FALLDEPTHIS30') <br /> ' 11 SOIL BORING O HAND AUGER GROUTSPECIPICATIONS <br /> ❑OTHER: OOTHER- _ APPROX.BORING DEPTH n BOLTED TRAFFIC BOX or OSTOVEPIPE <br /> CONDUCTOR CASING PROPOSED (Ir YES,list specilications In comment section) <br /> COMMENTS! <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 propared this application and that the work wilt be done"in accordance with San Joaquin <br /> County Ordlne Ices,Rules and Regulations, <br /> and all applicable California State Laws. <br /> Signedx r`��"'"�-� TNlelGompany ��✓ S7?D�� [�,C7GG�a'S% <br /> Print Name Gam+..! ' Data .s�/a <br /> ' DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: �'�e� -� ���LCiC✓1f P�Ane f <br /> WORK PLAN DATED': 1, / <br /> Appllcegan Acceptad By cote lsaue Area 997 <br /> Grout Inspection Inspection By Date <br /> Destruction Inspection By Date <br /> ' COMMENTS I CONDITIONS: C /l^ <br /> ACCOUNTINGONLY: AIDE FAC#. <br /> PE CODES " FEE INFO AMOUNMREMITTED CHECKA REC'DBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> IWI <br /> C-57_ WC_ WAIVER;_, C-57 Letter of Authorization to sign permit`Encroachment doc_-- <br /> ' BHD 29-02-001 <br /> tJ22roa <br />