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Apr, 1 20 3 9' 27APlnrcr CpriFnx l rn r 6r�a l t." .iJ�(l <br /> ! <br /> San Jonquin County Ir <br /> Environmental Health Department- SITE <br /> 304 Fast.Weber Avenue, arc)door, Stockton, LA 952 � J TIGATION <br /> • <br /> (M)468-3449 1~ax, (209)468-3433 Web- -Nv.sjgov.org/e1Zd !i 1l ZC_J�" UNIT IV <br /> MAP 2 1 <br /> - Well Permit Application `J 200 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISQRONMEN i h'EA <br /> Application is hereby made to San Joaquin County for a permit to-construct andlor install tliL work desorib d. I )i4o ';f,Tade In compliance with San <br /> Joaquin County Development Title,Chapter 9.91 15.3 and the Standards of San Joaquin Cotinty Environmental Health Department, <br /> Assessors <br /> WELL Location 345 N 'Yosemite street Cross Street A Fremont Rt.Clty Svoctetotj Zip 95203 Parcel# 135-260-11 <br /> PROPERTY w <br /> OwnerTerrrr_McDonald, <br /> I Address =45 N Yosem_te StreetCityS oc'.rton Zip9S203 Phone# {209)455-220n <br /> C-57 Cantradof e I �rIla - Address 7 X00 PjVrfie A Ve Cjy EUrt L Zipjj�02Lic#67261�Phone# d t- r0+0 <br /> Consultant ISub C}tr - .+ a, AddresS -�- S; City SZOckCon Lir# 6F 0227 Phone#--ittl9} i5% _coC <br /> GIS Coordinates:X ,y Township Range 5eclion <br /> WORK TD BE PERF RMFDr <br /> B NEW WELL I BORING (CPT,GEOPROBF, HYDROPiJNCH,HAND-AUGER, THER') N BEST RUCTION (choose type below) I <br /> [t SOIL BORING# MW-10,..-11 -12 r J D OVER-BORE. DIAMETER <br /> Q WELL# _ 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIQN}S .. <br /> COMMENTS: <br /> I <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICAT! NS <br /> XMONITORING ff HOLLOW STEM DIA.OF BOREHOLE 8" (J ULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS SchedlE 40TYPE OF CASING; p STEEL ffPVO BOTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH CF GROUT SEAL TRI~MIE TYPE TO BE USED: 0 AUGERS d HOSE <br /> 0 AtR SPARGEI OZONE (;PUSH POINT(CP OF CPT)GROUT SEAL PUMPED: 0 Ye f No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS x ar land Neat Cement <br /> 0 OTHER: 0 OTHER APPROX.BORING DEPTH 33' 20' '3y IT BOLTED TRAFFIC BOX or 0 STOVE PIPE i <br /> CONDUCTOR CASING PP.OPO ED (i,` YES,list specifications in comment section) <br /> COMMENTS' # <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGR EMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUI ED FOR INSPECTIONS, <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin <br /> County Or ynances, a and R nd all applicable California State Laws. <br /> Signsdx �' Titie/Comp ry fir.af itsigLIAGE <br /> PrintNsrne Gav_r D, McCreary Date i1 Marca 2008 <br /> DEPARTMENT USE. ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED. <br /> ApplioaUori Acte ted i3 � � D Ite Issued �' Area <br /> Grout Inspection Sy ,' =`u a� L t— Date/-//i f Final I spection By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: tv <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Lvi- <br /> C-57— WCC WA1VUP, C-57 Letter of Author'Izot[on to sign permit Encrocchment doc� <br /> EHD 29.02.001 . <br />