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09./t72/2.009 1.0:.21 2094683433 EHD PAGE 05 <br /> a - <br /> Environmental Health Taepa>rfiment Tt= <br /> 304 East WeberAvnue 3rd F1oar, Staclrotx,"CA 95202 EC idl-T, l <br /> (209)468-3449 Fax: (209j468-3933 Web:vYtvw,sjgoV.orglel?d <br /> AQP 3:Y zOg4 NIT IV . <br /> �.. WellPermit Application.. <br /> NViR ii MENT HEALTH- <br /> NON RBFUNDABLI;PERMITEXRIRE51 YEAR FROM CtATgii SLUED p C� t/l � p _ <br /> +7� V d1.1 <br /> ApplipaE on ishereby�aC€e to Ban Jaaqufn Courtly for a:pertnFt to cons#n rCt al3dlOr.ir�stall the work dascri �tl. .Thi3°applica#ionas ma, a in cnmpllanre.witn Sart --.--- -. <br /> Joaquin County nevelopment Ttla,Chapter 8-1716.3-anti the Standards of Sart Joaquin County_Environmental Health Department:, <br /> WELL,Lacatlo" 4571. Pacific i�venue Rose <br /> n Gross Strcot_.. City Zip arca!# <br /> e Marie Stcelti Qn 95207 So11Q-,230c11 <br /> 0%OP4: Ar taC7cEOX1 LS_L1 951-1207 <br /> Owngr ='st k']fdLt _ Addresfi 6265 Crooked stick C S Zip�Phone# <br /> Diamond Spr�.a e <br /> A11 well Af,andonmez� 6624 lfercklandise way S 484359 590 644 2609 <br /> C3Y.Cen#r"ab#vr _ �ddr�ys City ztp 95629:ic#__ Phones <br /> Consuilantl50Cntr Adya,6�' nnRnvirnnrnartalA41OM6S 837 Shaw P Glty S 6Ckton Lip# pn'f�i7 _ Phone# f3.n9t467-7.prtS7.OttS <br /> GIS.Coordinates:X Y._ _ Township Rang9__. Secton <br /> ORK"TO':gE P 4FiMEIS:. <br /> a NEW WELD;t BORING"•':(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,QTHE w) :.DESTRUCTION (Choose type below) <br /> p SPIT.BORING:# -N OVER-BORE. DIAMETER Ruth/2ingh <br /> pWeLL#_AW f:: . owe _7w'r�' 'V&J-"I ;j rg� t 1Jt;3 1 ' �PRESSUREGROUT; <br /> u!Other_ 1r{,y.4 }��,�-� GROUT SP.ECIF.ICATION_ S )�C.tland <br /> COMMENTS; <br /> :MP-E OF wgi.L INSTALLARgN TYPE CONISTRUGTIt3N SerzCtFICATiONS <br /> IT MONITORING J]HOLLOW STEM DIA OF BOREHOLE 'MULTIPLE CASINGS O MULTI-LEVEE. WELL CASING D A: 2/6-inah <br /> EXTRACT40N 11 AIR HAMMERIDRIVEN CASING THICKNESS TYPEOFCASING. U STEEL n PVC UOTHER: <br /> 'O VAPOR" TI MUD ROTARY DEPTH OF GROUT SEAL TREMI E TYPE TO BE USED: Q AUGER$- O HOSE <br /> a AIR SPARGE!OZONE h PU5H POINT(GP or CPT)GROUT SEAL PUMPM-, 11 Yes 11 No (NOTE:MAXIMUM FREE-FALL DEP'T'H IS 301) <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 11 OTHER: G OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (ri YES.list spedficallons in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE'BORINGS REQUIRE.EAGCESS:AGREEMENTOR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED.POWINSPECTIONS. <br /> ,.he.reby certify that I have prepared this application and-that the wark w111:he done in accordance with Sart Joaquin <br /> County Ordinances, Rules: .Regulations,and all applicable California State Laws. Ly <br /> Signed x Wi3 lF TitletCompany 46 <br /> Pdnt Name �1 pate D <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRES : 1 L G <br /> WO "PLAN DATEC]_ to a <br /> Appffcatlon Accepted 8y ate Issued � 1 i I("i-- Area '�! <br /> GroutInspectlonBy_ Date Final lnspectionEly tiT Date <br /> De.g UCtion Inspectlon By Date <br /> C7004ENTS LCONDtTIONS: <br /> ACCOUNTING ONLY: AID# FACA <br /> FE COVES FI=E INFO 'AMOUNT REMITTED CHECK*: REG'D BY DATE/ �E�RyMIT l SERVICE REQUEST# INVOICE <br /> '5,y,> as V"�w 4 Com`"t t�f( .� �# S ;Z �t <br /> C-57�WCC -WATVER� C-57 Letter of Authorization to sign permit�/Encroachment doc— <br /> EHID 29-02-001 <br /> 6/22Jfl4 <br />