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FILE COPY
<br /> SE0
<br /> 2607
<br /> San Joaquin County `l"t,'VIRONN EN i "
<br /> rw_ ".. Environmental Health Department PPSS ,��11i�� ,, TE
<br /> �=MIt T
<br /> 600 E.Main Street,Stockton,CA 95202-3029 MITIGATION
<br /> ` &3ov_or ?olid
<br /> -- � (209)468-3449 Far:(209)468-3433 Web:www•sjg $ UNIT IV
<br /> Well Permit Application ~---�---�
<br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM(SATE tSSUED
<br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San
<br /> scaqu€n County Development Tltle,Chapter E-1115.3 and the Standards of San Joaquin County Environmantal Health Departmert.
<br /> Assessar-
<br /> WELLLocatian 25355 1V Hwy 99 Cross E Calim y_:ta ffy ACatnpo Zip 95220 Parr,$# ��u4�_t
<br /> M .. _—_._..___..._............. T
<br /> PROPERTY
<br /> Ownersa:l loam Co=:rvy P. Worx AdGr&gg'81Sy, t+a:e.lton F,ve. City tocktrn Zlp?51_7_,il5 Phoefi.
<br /> C-57 ContfaCtor Gr_.3gL.r__ar.n�-Addregs_,..95 C` llcWe Rc>d1 City _.Z€p_5553 U40 5'iiP0onE4 975,311 5800
<br /> Consultant!SubCntr-- ERI _ Addres5_60, lv,i?cro�eil Elvd. City peta]1 m&UCN,_ is-st1 Phones+ TQ7.766,2000
<br /> GIS Coordinates:X 33.2369028 Y -123.2Gfi?844 Township Ranga. Section
<br /> WORK TO BE PERFORMED:
<br /> CKNEW WELL I BERING CPT,GEOPROOE.HYDROPUNCH,HAND-AUCSFR,OTHER') D DESTRUCTION (choose type below)
<br /> gSOIL HOR'iNGS . � a OVER-BORE. DIAMETER --
<br /> 1]WELL* _ a PRESSURa GROUT
<br /> a`ether- GROUT SPECIPICATMNS ____..___
<br /> TYPE OF VVELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS
<br /> 0 MONITORING a HOLLCW STEh1 D',A_OF BOREHCLE?•.2`•"[J tYtULTIPLE CASSNGS [I IdULTI-LEVEL WELL CASING DIA:
<br /> a EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER:
<br /> a VAPOR 0 NIUO R DTARY DEPTH OF GROUT SEAL 14J' TREMIE TYPE TO BE USED: GAUGERS SHDSE
<br /> a AIR SPARGE+OZONE 4PUSH POINT(GP or CPT)GRCUT SEAL PUMPED: ILYes 0 No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30')
<br /> 0S01180r-dNG 0 HAND AUGER GROUT 9PEC]FjCATIONS Cemellr u= w <5s urs: sodium benLoritc
<br /> a
<br /> OTHER:______[]OTHER___ APPROX.BORINGS DEPTH 140' a BOLTED TRAFFIC BOX or a STOVE PIPE
<br /> CONDUCTOR CASING PROPOSED (N YES list specif ations In comment section)
<br /> COMMENTS: sic public uork3 Encroachmel_ pernit application attached. under review.
<br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS.
<br /> 48�WbRKING HOURS NOTICE REQUIRED FOR INSPECTIONS.
<br /> I heretly certify that I have pre red this application and that the work will be done In accordance with San Joaquin
<br /> County Ord Rules a° d aulations,and. app licable Callfornia State Laws.
<br /> Sicced x__ l f.� w TiiWCompanPrint Name 4 Dale
<br /> DEPARTMENT USE ONLY
<br /> SITE MAP IN UNIT IV FILE,ADDRESS: �� �S � a -w
<br /> WORK PLAN DATED: �'j;i
<br /> 33
<br /> Application Accepted By \1 t ( )^7? ' _Date Issued L __Area
<br /> Grout Inspection By ' I„`�,� i1e ';f'-2W Date_IFira!lnspectfan By ate 1� 2S � 7
<br /> Vestruction Inspection By gnse
<br /> COMMENTS)CONDITIONS:-
<br /> .. _�ta�m*�:�:.�...,,;,�°�x: .:�.,:;.-..:,.:.:M.: ..�:;.'_. ...::.:rawer._... e,.'=::4,.,F-tx+-�:aaw�rwc-=•.,,,.,_s,.y .
<br /> %C'COUNTING ONLY: E AILm FAGS
<br /> CODES FEE f NFO AMOUNT REMTTEO CHECKS RECD BY DATE PERINT l SEAVIGE REQUEST 0 11 VOICE
<br /> � 50 i $cr y, a �� - 9 zl u'� sR# �, ter`. 3
<br /> C-57�,,. _, WC -WAIVER ,,, C-57 letter of Authorization to Sign permit,•encroachment dock,.
<br /> LIID 29-02-001 web
<br /> 6P-2,0A
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