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Apr 28 05 11 : 30a p. 5 <br /> no <br /> ,oPa� San Joaquin County <br /> N p% Environmental Health Deparii&d .1 ?005 SITE <br /> 304 East Weber Avenue,3rd Floor, Stoc'9PMRMW,g MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web: wwwR [�_j,�-tE�Li f <br /> Il°iE`��ICEs UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the StandardsofSan Joaquin County Envlron ental Healtic epartment. <br /> /" 0 ��r_ S-O' LY Y Cross Street I� ( F gJ y . All J. ssessor' (0W f <br /> WELLLocatlon nn Cit Zi Parcel#` (U <br /> PROP TY �icr'��J �j q <br /> Owner,5L__ba_ �,,r`Address 7�Qy• w (p� Cityy,��I AV s ZIp�N J J one# r <br /> C-57 Contractorf L UNC�v Address 1 S� �l Q����,+/�N�/�j f'fpf,� CitylY/l �lp ILiaphone# <br /> Consultant/Sub Cnlr C Address��Y"`�r✓J r�, [Y CitY� r/riu+tn.—LVPhone# �/0 ._! ! / `374 <br /> GIS Coordinates: Y ! dJ vY ,Township _Range KJ Section w <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL/BORING fC.PT G�OPR 6 li,Y ROPUNC HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> SOIL`#RIt�C3# �j„( / sl�' � OVER-BORE. DIAMETER <br /> p*Other i p PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: S 72f <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING HOLLOW STEM DIA.OF BOREHOL " " <br /> 0 MULTIPLE CASINGS a MULTI-LEVEL. WELL CASING DIA: <br /> 0 EXTRACTION o AIR HAMMER/DRIVEN CASING THICKNESS 40 TYPE OF CASING: 0 STEEL )t'4C Q OTHER: <br /> 0 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 0--& TREMIE TYPE TO BE USED: VUGERS V OSE <br /> p AIR SPARGE/OZONE XPUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Y s p NoNOTE: AXIM FREE-FALL DEPTH IS 301) <br /> SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> p OTHER:_0 OTHER APPROX.BORING DEPTH C1 BOLTED TRAFFIC BOX or D STOVE PIPE <br /> ,1 CONDUCTOR CASING PROPOSE (if YES,list ssppecificati�onns�iinn�comment section) <br /> COMMENTS: '1C1 !>i V G�i'l� � I�e/f��7o1 1 t,&;uI�'~� /1�/ FUXI L+'f�7/GZct �r <br /> v(�-1 VV(33 M it, CrP-V'e-r T&77 -Fier;M Se*Cr"�IC15::--Tv Tza7/, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquln <br /> County Ordis, R and R ulations,and all applicable California State Laws. <br /> nan <br /> Signed xJJJW� ^^-z,_� Title/CompanyriZ�Ct�-Z�C•`f(�N%?rf) (r- <br /> Print Name rl- �v I Z Date ��L �G✓ �� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted B <br /> pP p Y -F 1Date Issued OS Area__1�__/ <br /> Grout Inspection By Nit. Date N 7r Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> b l �" 61 / S 2r k/ � s�� D S R# ©oil Zl 71,5, <br /> C-57_ WC--WAIVERC-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> E1,ID 29-02-001 <br /> 6/22/04 <br />