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41 2094683433 FIFTH FLODR <br /> WELL ERMIT APPLICATION FC—M SITE <br /> SAN JOAQUIN COUNTYITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) M <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ppl,cat,on Is hereby made to San.loagwrn County for a permit to construct and/or rnThis;the work descntTh, apP6cat,on,s made in oomphance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and tho Standards of San Joaquin County Environmental Health Department <br /> WELL Location <br /> woo #j_ Yq�m4 �. _ cross street Univ 1d.city�+'rkc�- ZIP Prce� o�33 <br /> PROPERTY COrdna lam( p 4 ` <br /> Owner NaA� �lNS1W 3�"`� �Address pebw oyk City lU.a - Zjp 9• 2-SPhonel r �1 �a X7511 <br /> �4, z `�� LK#`}gsr+rS Phone12Sr-�313rSSDO <br /> C-57 Contractor CZ Vt l(t Addt2ss I IDwc. caYN +tom- P <br /> Ratig'W Address <br /> Consultant/Sub Cntr � <br /> 1~nu _$off zSCi C, L,ci���Phonei117o r rr <br /> GIS Coordinates X Y ,Townmhrp Range Section <br /> WORK TO BE PERFORMED- <br /> NEW WELL 1 BORING (CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,CiMiER') Q DESTRUCTION (moose type below) <br /> a SOIL BORING# Q OVER-BORE DIAMETER <br /> WWELL#_fAILI—A 1]PRESSURE GROUT <br /> I]'Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL IFISTALLAriON TYPE CONSTRUGTIOti SPE!ZIC <br /> ATIONS 211 <br /> .ILMONrrORING &HOLLOW STEM DIA OF BOREHOLE p MULTIPLE CASINGS g MULTI-LEVEL WELL CASING DIA <br /> 1]EXTRACTION a AIR HAMMEPJDRNEN CASING THicKNE55Sc� 40 TYPE OF CASING Q STEEL PVC a OTHER <br /> isOR Q MUD ROTARY DEPTH OF GROUT SEAL I TREMIE TYPE TO SE USED SAUGERS&'.WHOSE <br /> SPARGE/OZONE 1]PUSH POINT(GP or CPI)GROUT SEAL PUMPED 1]Yes 41I:No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> n so!L BORING tl HAND AUGER GROUT SPECIFICATIONS CI4Q,vt-at <br /> U OTHER_ n OTHER APPROX.BORING DEPTH t.•3S� U BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED lL O (,f yES,list specfiicabons In comment section) <br /> COMMENTS <br /> NOTE' OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordl a ulations,and all applicable California State Laws. <br /> Signed x T1tWCompeny��sa�ril�irfi�r � y�r rr/�il�G <br /> Date l� r� <br /> Print Norma r'r EPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS:_ 1 1 4 O V4. Y D S e s rt ,+¢ � <br /> WORK PLAN DATED: reb r ,r 10 0 <br /> Application Accepted By V Da6a Issued !I J 1) Q 3 Ama f S 9 <br /> Grout Inspection By Date Fnal Inspection By Dale <br /> Destruction Inspecbon By Date <br /> COMMENTS/CONDITIONS: <br /> W-acil <br /> UNTING ONLY. AID# FAiCU <br /> ODES FEE INFO AMOUNT REMITTED CHECK# REC D BY DATE PERMrT I SERVICE REQUEST# INVOICE <br /> 'ol 89.00 gq. Ov i8o1 SR# 4o3G OD7 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />