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DD <br /> FILE COPY <br /> ED <br /> a, <br />� c. • • -, San Joaquin County 00 <br /> Environmental Health De alrtmen- EN VI OT ' ITE <br /> 600 E:MainStreet;Stockkon,CA 952{12-3029 PEgtto,i E N. <br /> (209)468-3449 Favi: (209)468-3433 11reb:www.sjggv.orglehrl IT lV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED <br /> Application is hereby;made to San Joaquin County for a permit to construct sndlor install the work described. This application is made in compliance with San <br /> Joaquin County Development Titte,Chapter 9-1116.3 and the Standards of San Joaqufn County Environmental Health Department. <br /> Assessors <br /> WELL Location s 25355 N Hwy 99 Cross Street E Calim yrnaCil Acam o.-_ 7i 95220 Farrah. OOS-143-02 <br /> PROPERTY <br /> Owner MEst:S Pas sx M 21'06 TRVv9T Addr:60 783 Los Flores Court CRY G61L.� _Zip 956:32 Phone#_ <br /> C•57 Contractar Gregg nrillinq------AddresS 950 Howe Read GIy K�rtinez ZJp 9455.3 Li[#aeS155 Ptlone#925-.313.5800. <br /> Cons ultantISub cntr ERI Address6o; N. City Lataluna.LicRxt_ :r-szra8spry*oe#707,'766.2000 <br /> G1S Coordinates:X_38.2-I6PO1B y -121.26 8'7349 Township_. - Prange, 5ectiort�—_ <br /> WORK TO SE PFftFOR1IN£M <br /> [KNEW WELL/BORING. (CPT.GEOPROBE,HYDROPUNCH,HAND.AUGER,OTHER'{ d DESTRUCTION (choose type below} <br /> T <br /> KSOIL BiDANG x CPT2 An&—ALP__3 0011ER-BORE, DIAMETER. <br /> 0 VVIELL*�° F _ .. a PRESSURE,GROUT <br /> p"Other.... ­ .. GROUT SPEC1FiCATIONS. �- <br /> COMMENTS:_ <br /> I TYPE OF WELL 1N ALLA ION TYPf CONSTRUCTION SPECIFLCATIONS <br /> [)?MONITORING .0 HOLLDYV STEM DIA,OF BON EHOLE2�25"a MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA:___ <br /> p EXTRACTION p AIR HAMM E RID RIVEN CASING THICKNESS TYPE OF CASING: .p STEEL D PVC p OTHER: _ <br /> p VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL. '-y a' TRFMIE TYPE TO BE USED: p AUGERS RHOSE <br /> 0 AIR SPARGE/020NE 9PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ffYes p No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30'). <br /> 11 SOIL BORING i a HAND AUGER GROUT SPECIFICATIONS, tri._rkL grout w/ <5 pone sodium. bentonite._ <br /> � . <br /> II O7HER: 1]OTHER_ �- APPRDX,BORING DEPTH 140" .0 BOLTED TRAFFIC BOX or II STOVE RIPE <br /> CONDUCTOR CASING PROPOSED,_ (ff YES,list specifications in comment section) <br /> COMMENTS:—' <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING FLOURS NOTICE REQUIRED FOR INSPECTION$- <br /> 1 hereby q r._V ;jYiave prep d his application and that the work will be done in accordance with San Joaquin <br /> County L , 'tiles a R' tions,and all applicable California State Laws <br /> ' � , r� <br /> Signed x _ "; 1 w,„ �7i11elcompany r `� <br /> Flint Name.., <br /> DEPARTMENT.USE ONLY <br /> SITE MAP IN UNIT IV FILE,A DRESS: <br /> y <br /> WORK PLAN DATED: V ! <br /> Applicatlar Accepted By e/! r Date Issued_. �. z-r'. Q Area <br /> I Grout Inspection Final Inspection By ate__-,_10 - 30 -O 7 <br /> Dnsrruction inspection a, Dr-1e <br /> COMMENTS I CONDITIONS <br /> e. ' "' "" - _ <br /> � :Basra-'m-.�.�'e�ec�sv� :g„'r•'— r� :=.�.. <br /> ,V <br /> i <br /> ti rTi''*iC.'3hfu,a ^;Iwo FACS ` <br /> ..,........, « <br /> €`011E6 FE£tNF11 l4iIIt319ltT R!tyfITTEO CHECK B R1 C'D J3Y. DATE. PERMIT 13ERVIGE REQUEST ii INI/OICE <br /> 3SU l Sg 89. bU .2G5�3 SR#061, <br /> d Z <br /> C-57 WC,.,^WAIUER_ C-57 Letter of Authorization to sign permit—(encroachment doe— <br /> EHD 29-(l2-4Di wcb <br /> f6)22104 <br /> f <br />