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•09/92/2009 10:21 2094583433 EHD PAGE 02 <br /> San oaquin,County <br /> -tivironimen h Aealth.Depart � D SITS <br /> !GA <br /> !T TION <br /> K 304 E$st Webar-l3,venue;3rd FSaor,5tocic#o • .. .• <br /> (209)46&3449 Fax:(209)46S-343 deb:uvww.Sj90v:(.Ay&8.1 2009 UNIT IV <br /> .r Well:Pel�rnit A.ppllcatio'n. ENVIROWENt ACTH; <br /> J R /�+ Sym <br /> NON=REFUNDABLE PERMIT 1 C°IRFS 1 YEAR FROM 17ATE 13kVWT+`a�1r1U . <br /> Application i6 hereby made t0 San Jo2quSn.County.f6r a pern)d to cork;hsct aiidlor install th my Ern+r nWorklmetaVhHealpth�ep2rlrn nada in compllaace v San <br /> Joaquin,CduntjjDevelopment Tlife;Gr apter t}1115.3 and the Stat3it8rds.ot San Joaqul ASS"So'$11.0-234.-23 <br /> Rose Ncarie ry: Stoc� kt��n 2Sp 952a7 ParC81# <br /> WELL' tion <br /> 4515 PaciLis Avenue cross$treet�� 1 <br /> PROPERTY One *7nonald° Plaza cityOak Brock Zip 50-23 Phoned X535) 623- 170 <br /> Qwner•Me A4pajdB Care Address— Y m4nr d SPrfn56 4A x"59 530 64h 2609 <br /> All wej. ..Ahandcjnment 6626 rlercnandiee Nay Cid �ZIP95679Phone#�-- <br /> Address <br /> C 57 bd6i actOt '� 3 <br /> SEockton LiC#tirtn9�7 Phone# t212- adi:2co� <br /> AddCass 837 Shaw Rd Gity__t-___.�_ <br /> Consultant!Sub'Cnlr' „ ' . <br /> O1S Cgprdinalas:X` ,Y <br /> Township Range SectiOrt <br /> R1T BPE OR <br /> (choose below)M CH,HNq- G , Ff�RSOREa-NEW WELL1110RING (CPT,GEOPROBE,HYDRD AMETER a_ h <br /> p$OIL BORING# - $WPRESSURE.GROUT <br /> aWrLL# t+tLJ '1117 fN! GROUT SPECIFICATIONS _Pnx l ttd� <br /> - lar <br /> CQMNiENTS: <br /> YPE OFYIIE_L_L I TALL 'ttONT PB CON tRUC ONSPECIFICATION3 a-inch <br /> T <br /> �MQNlTOR1NG $H4LLOW STEM DA,OF BOREHOLE �i 11ULT1PLE CASINGS (]MULTI-LEVEL 1NEI L CASING <br /> t7tA — <br /> AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL U PVC Ili OTHVR:, - <br /> 0 ExTRP.CTION 4 , HOSE <br /> p VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL�TREMIE TlPE TO$E U51 �: 17 AUGEP,S. [� <br /> 0 AIR SPARGE!OZONE a PUSH POINT(GP or GP-0 GROUT SEAL PUMPED: 4 yes 1]NO (NOTE: NIAXIMLlM Ft�EE�FbI-i QEp�IS�4'� <br /> SOIL BORING a HAND AUGER GROUT SPECIFICATIONS a BOLTED TRAFFIC BOX or I]STOVE PIPE <br /> OTNER��..� APPR07C, <br /> BORING DEPTH <br /> 1S OTH5R.�1 ,f YES,list speolflcati0ns in Comment section) <br /> CONDUCTOR CA'�'INCa PROpOSED•,�,.�.�(� <br /> COMMENTS, <br /> NATE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 481h1ORKMIO HOURS NOTICE R!"CII.IIRF-D 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 �Or _ <br /> 5lgnad x dinanceS,�Rules. RegUlations,and all applicable California Stat I,aws. <br /> TAIe1C0MP3ny <br /> � �f <br /> print Name <br /> • DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Slid ` <br /> WORKPLAN PAYED: io a <br /> - t Area �r— <br /> Date issued <br /> Application Accepted By Final Inspection By Date <br /> Grout tASP�CtQn 13y___ <br /> 3y Rate <br /> oeslruc4an Inspection By <br /> Date <br /> COMMENTS 1 CONpITIONS: <br /> ACCOUNTING ONLY: AID# FAt; <br /> ERVICE REQUEST# 1NVOlG1; <br /> pe CODES FEINFO AMOUNT RBMIVED CHECK# REC R BY DATE <br /> PlrRMIT f S <br /> E <br /> C-57✓ WWAIVEP,_ C-57 letter of Authorization to sign permit!=-�'Encroachment doC,____ <br /> EHb 29.02-041 <br /> 6�10d , <br />