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08/09/2005 14 24 2094683433 EHD PAGE 02 <br /> aur - lz �f/ r- an Joaquin County ,-r <br /> iuilmental Health Department SITE <br /> e a�V 304 Avenue,3rd Floor, Stockton, CA 95202 MI I Y IllN <br /> 209)4xrWeber <br /> 9 Fax (209)468-3433 Web www s}gov orglebd <br /> 4 E PSR MENS HFa II Permit Application <br /> MIT/SERV.*CESS <br /> Nom-REFUNDAESLI:PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> App[Ication Is hereby trade to San Joaquin County for a permit to oonstruct and/or install the woric desanbed This application is made in complianca vnth San <br /> Joaquin County Development Title,Chapter 9-1115 S and the Standards of San Joaquin County Environmental Health DepartmentAssessors <br /> (Dam ` e Z[pV _Pamel#- t�n7 G - <br /> WELL Lvcaelon �- ross Street �� �-Gdy <br /> PROPERTY Zi 'f0 Phone#fA ��'S"� <br /> Owner—"L Address caD IN�rJ$T . City P` 'p <br /> C-57 Contractor , 1,50 <br /> Address <br /> City ;� p� LiC# Phene# l3 ` � <br /> Consultant/Sub Cnt �►iJl <br /> r� &fL►+� j1i Address5� Phone Da <br /> Cls Coordinates <br /> y_______Townahip Range Secdon__- <br /> 4M0H6K2T0.j3E PERFORMED DESTRUCTION (choose type below) <br /> NEW LL/BORING, (CPT GEOPfiOBE,HYDROPUNCH,HAND•AUGER,OTHER•) OVER-BODE DIAMETER <br /> SOIL BORING# — d PRESSURE GROUT <br /> WELL# L.�^ GROUT SPEC IFICATIOfJS <br /> d'Other ►x <br /> COMMENTS —I s � � <br /> TYPE O LL N ALL ATION TYPE CONST UCTION SPECIFICATIONS =r c <br /> U)-Qd MONITORING HOLLOW STEM DIA OF BOREHOLE, U MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA D <br /> Q EXTRACTION a AIR HAMMEWDR1VEN CASING THICKNESS TYPE OF CASANG [I STEEL EMIE TYPE o BE V(PV []AUGERS[I OTHER <br /> I]HOSE <br /> APOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br />')A.OIR SPARGEI OZONE b PUSH POINT(GP or CPT)GROUT SEAL PUMPED 11 Yes 4No (NOTE* MAXIMUM FREE-FALL DEPTH IS 30') <br />-r ;ySOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 15 BOLTED TRAFFIC 80X or a STOVE PIPE <br /> 13 OTHER n OTWF-R APPROX. BORING DEPTH <br /> CONDUCTOR CASING PROPOSED (If YES,list speclfloatlons in comment section) <br /> 0.Dlt3 1. #rZ <br /> Cd14tM D Y <br /> p�_t a S�s•..�e� 30 3'3° <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 epare this application and that the work will be done In accordance with San Joaquin <br /> Court ran s, Rule a ulatlons, and all applicable California State Laws, <br /> Signed TlUeICompany 141, 7� <br /> Date <br /> Pent Nama <br /> DEPARTMENT USE ONLY <br /> Si7E MAP IN UNIT IV FILE,ADDRESS: Z 2 a Rc <br /> WORK PLAN DATED: a 0 <br /> l _ <br /> Application Accepted ByDate Issued_V i of o r i tt Z , rn R <br /> Grout Inspection By Date_Final Final Inspection By Date <br /> Destruction Inspeobor.By Date <br /> _ 2�4 VA kit <br /> COMMENTS I CONDMON <br /> ACCOUNTING ONLY AID# FAC-4 <br /> PE COPES FEEINFO AMOUNT REMITTED CHECK ik REC'D BY DATt2 PERMfI• SERVICE REQUES 1 d E <br /> 3So� 3GS.00 SGS. d� � E <br /> C-$7 WC=WAIVER C-57 Letter of Authorization to sign permit EncrcaChMent doc <br /> EFM 290-02AGI <br /> 6122/04 <br />