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1G/GD/ LGGL 1G:4/ LGJ400J43J rir im rt_uut[ HAUS 04 <br /> �����o D WELL PERMIT APPLICATION FO� SITE <br /> �/ L� SAN JOAQUIN COUNTY MITIGATION <br /> JUN 2 3 2004 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> ENVIRONMENT HEALTH (209) 468-3449 <br /> PERMIT/SERVICES NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DOTE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in Compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department 3a0-$j` <br /> � r� Assessor ,L <br /> WELL Location 13ZO S, �Af lAytw'r0 .S'r, Cross Street TAMA r.cl( /Ir.CIty GAIL/ 7JP .l '0 Parcel# 1 - � <br /> PROPERTYOvmer lrlrAU T, VAK.Iedar.$ Address /YI d S, Sf. City ���/ Zip S.�YOPhonoi! (209)3'AY-Y/IS <br /> C-57 contractor lrrag /,/r:Ilan Address 960 Rol. YSjti �SZq_ j/�`5�009 <br /> Consultant/Sub Cntr W v. Str.AF Cityre.rorc( V Phone# <br /> v <br /> GIS Coordinates:X ,Y .Township ly" 3 RangO0 Section 1Z <br /> WORK TO BE PERFORMED: <br /> )[NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) n DESTRUCTION (choose type below) <br /> SOIL BORING# D OVERBORE. DIAMETER <br /> SWELL# D S - 7 D PRESSURE GROUT <br /> $'Other CPI- II i:PT- II GROUT SPECIFICATIONS <br /> COMMlNTS�tP1-2! ZPri It; ZP1 131.;,4 1) OS-I : 06ceyraf;or wto <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 06$l ry t A Lve ll O S-z it <br /> �AMONITORING I)A HOLLOW STEM DIA.OFBOREHOLE /O" 0 MULTIPLE CASINGS DMULTI-LEVEL WELLCASINGDIA: <br /> D EXTRACTION D AIR HAMMERIDRIVEN CASING THICKNESS -9A- 40 TYPE OF CASING: D STEEL ?1/C n OTHER <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL .SAI P. TREMIE TYPE TO 13E USED: .'AUGERS D HOSE <br /> D AIR SPARGE/OZONE))II PUSH POINT(GP or CPT)GROUT SEAL PUMPED: $Yes D No (NOTE: MAXIMU11i��REE-FALL DEPTH IS 301) <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS /V eA f i;t M e f Tpr)c��+.;:d. <br /> L= ri ew. P,'Pt <br /> OTHER: t Pf D OTHER APPROX.BORING DEPTH OLTED TRAFFIC BOX or []STOVEPIPE <br /> CONDUCTOR CASINGPROPOSED A r (it YES,list specifications in comment section) <br /> COMMENTS: f B•.i.. ^'u2 AI:. I7r,i O 3 ' i" Irr �f' w ,ds <br /> NOTE: OFFSITE BORINGS REQUIR 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 Regulations,and all applicable California State Laws, � <br /> Signed �t [ Tide/Company AxAjAl '/ CrWz-1%^C <br /> PrintName v�EM wff y J0 /r r Dale O �( <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: p , <br /> 4pplicetion Aompted By ` Date Issued �i Z- D Area <br /> 3rout Inspection By —m Date 1� Final Inspection By Date <br /> Destruction Inspection By Date <br /> :OMMENTS I CONDITIONS: C-(_ <br /> ACCOUNTINGONLY: AID# I FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> L21 ff-I 35 1 06709 ,14 SR#po�� S7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment 1oc_ 9/30/02 <br />