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- San Joaquin County SITE <br /> Environmental Health Department <br /> 600 E.Main Street,Stockton,CA 95202-302 � IGATION <br /> -- ax: 111V <br /> _ A <br /> Well Permit Application AI+R 2 0 2010 <br /> NONatEFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATEe In compliance XaSSn <br /> Application is hereby made to San Joaquin County for a permit to coretrua andlor Install Itle WO*d Assessors J63'3.%-001 <br /> �3� QO/ <br /> 0. <br /> Joaquin County Development Title,Chapter&1115.3�Id theme Standards I Sin Joaquin County Etrnri_ro '+ Wrt nt- -00 <br /> 2. 5 AC /y..yv Dr. cross slreel d 11;i � ry J —zip 5Z0 P�cete .tc <br /> WELL Location yupc0.a+>t---� <br /> P�rERn�.-*� ►fSTo.l.tan Addese 2�Od A/. —Crly S ,, z�p95 P —S'7y0 <br /> !� Odnc-31r! <br /> C-57 Contractor yL&&&- X r lNL JtddressSZ— L�� �LvD City1_R:NLLQ1�Pi T+' <br /> � ' Phonylo9)Z3'1�OS/$ <br /> Consueant l Sub CneCandet'Ic�/1� C* Addre" /88 It Wir��3citysiecka.—L� —•--- <br /> GIs Coordinates:x 63228'944.89 ,r Z 16 L Zk b,0 q ,ToastshIP. I Rema G c Slaw '►' I <br /> Jc ArT"01dw- <br /> MRK TO E PER <br /> n NEW WELL/ (CPT, OPROBE YDROPUNCH.HAND-AUGER,OTHER? a OV <br /> ER-BORE.1 DIAM(ETTEER %De Debvi) <br /> 0 SOIL BORING f a PRESSURE GROUT <br /> D WELL# S."�")1 S r / I��s fJ�nJ GROUT SP <br /> /�ECIFICATIONStiff l b ( l 05 f w )'4/ <br /> pNar e L 'FYLwby �3nw+� �'^rtol <br /> COMMENTS: �1' ) Q T a"d' 3oF " <br /> TYPE OF WELL IN8TAt LAtION TYPE CONSTRUCTION SPECIFICAnM <br /> E MONITORING 0 HOLLOW STEM DIA-OF BOREHOLE-a!—' 0 MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION u AIR HAMMERORIVEN CASING THICKNESS TYPE OF CASING: g STEEL 0 PVC BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. B AUGERS a HOSE <br /> p AIR SPARGE/OZONE 101USH POINT(GP or CPT)GROIJT SEAL PUMPED: 8 Yes 0 No NOTE:MAM M UM FRE FALL DEPTH IS 30') <br /> SOIL BORING g HAND AUGER GROUT SPECIFICATIONS <br /> OTHER: B OTHER APPROX.BORING DEPTH 1 S-'?►' {&!1r 0 BOLTED TRAFFIC BOX a 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (N YES,fist specifications in comment section) <br /> r . t <br /> COMMENTS: d 11� "'��S n �-1—1fWs�-W�'s <br /> M12- j 41 <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 Ordinances,Rules Jill Regulations,and all applicable California State Laws. <br /> Signed x CZ !/ s Ttle/Comparry <br /> Pnnl Name_ I .$ `A Q& Date I O I <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: 3 f <br /> Application AcceptedY - Date Issued J Area <br /> Grout Inspection By Datej, Final Inspection By Date G <br /> Destruction Inspectlon dy Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY. AID# FACS <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK f RECD BY DATE PERMIT/SE CE REQUEST f INVOICE <br /> intoSol <br /> OL 8 <br /> C-57 WCC WAIVER_ C-57 Letter of Authorization to Sign permitZ-Encroachment clot_ <br /> EHD 29-02-001w 1) <br /> 6122/04 <br />