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64/19/2005 14 23 2094683433 FIFTH FLOOR PAGE 02 <br /> t,t <br /> San Joaquin County <br /> Environmental Health Department ; SITE <br /> 304 East Weber Avenue, Std Floor Stockton, CA 952 �' �� �"' MITIGATfON <br /> ` (209)468-3449 Fax (209)468-3433 Web Nvww sjgcpNgKd�j M�i�JT HEALTH UNIT IV <br /> Well Permit Application t'E''In'�'�' — <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1,55U Ea <br /> Appllcatlon is hereby made to San Joaquin County for a permit to construct and/or install the work described This application is made in eompl arce with San <br /> Joaquin County Development 71tle Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> 9Assessors <br /> WELL Location <br /> $6b� i pjtJ Cross Street ��4✓/ �CityTb� " Lp J Parcel# ~7 <br /> PROPERTY <br /> _ /W <br /> `Owner � /apPhone# �j <br /> C-57 Contractorr�-r.1 Address 3G S Dt7E� G'.,r� <br /> City <br /> ed Zop lrO7QLic 7 y-/d Phone# 6-t� B�'l6j <br /> Consultant I Sub Cntr gL"- ,> Addressal �✓L OA's Go.� d <br /> � Z .._,. City L�c# Pnone# <br /> GIS Coordinates X Y_ _ Township _Range Section <br /> WORT(TO BE PERFORMED, <br /> NEW WELL/BORING (OPT GEOPROBEr HYDROPUNCH HAND AUGER,OTHER") U DESTRUCTION (choose type below) <br /> 0 SOIL BORING# U OVER-50RE DIAMETER <br /> WELL# p PRE55URE GROUT <br /> 0"Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL MT ALLATIQN_7-YP_E H SPECIFIQATIONS <br /> 0 MpNfTOR1NG NOILOW STEM CIA OF SOREHot-F:,_—Lr 0 MULTIPLE CASINGS D MULTI LEVEL WELL CASING DIA ,r <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS� � TYPE OF CASING Q STEEL INPVC 0 OTHER <br /> XVAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL �,TREMIE TYPE T4 BE OSED D AUGERS XOSE <br /> O11 AIR SPARGEI OZONE n PUSH POINT(GP or CPT)GROU7 SEAL PUMPED E Yes ONO (NOTE MAXIMUM FREE-FALL DEPTH IS 30) <br /> IJSOILBORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> E OTHER 0 OTHER APPROX BORING DEPTH BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d YES lost spec,t3catlons in comment section) <br /> COMMENTS <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 OrdlrtarttieS fIl sand'Regulations, and all applicable California State Laws <br /> Signed x ! Tltle(Company <br /> � �f�yS <br /> Print Name __ date <br /> DEPARTMENT USE ONLY <br /> SITE MAIC IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN! DATED, p ,/ <br /> Application Accepted By f&f —o -�';^ _ Date Issued ?' /-7/6 S7— Area _ <br /> Grout Inspectlon By Date Flnal Inspectlon By Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS S C- <br /> ACCOUNTING ONLY AID# FAC4 <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 3n I C�7ii. � �/5 aI SR# 4�/ <br /> 0, 57� WC___-WAIVER— C-57 Letter of Authorl2atlon to sign permit_Encroachment doc_ <br /> EHD 29-02-001 <br /> 6122/04 <br />