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/tj,u I-II- iH I-LUUr N0. 5411 P. 3' eZ <br /> MAR. 19. 200P 12:49PM D;y�EK & ASSOCIATES <br /> WELL PERMIT APPLICATION FORM SITE, <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 466.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> ADDIIcalen is hereby made to San Joaquin County for a penult to construct and/or install the work described. Thls appticaiion is made in compliance with San <br /> Joaquin County Development Tile,Chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> AWegsar's <br /> I(n 7 F�Ls4 A IP It?t A V<. Dross Street Lts, l.nI.n• Giry S L k t°n zip 5 0 5 Darcal -oto <br /> WELL Location LL ���l _— <br /> PROPERTYOwner r'-I�' Fty1Y)IT1 Addresslfo 2N E.as� Alviht Aveciry S+o�kt-o� Zip X205 phone6 1-0 4 3. 1033 <br /> GCiyip ucttpnoneu 1,3$• <br /> C-57CoabaatgrCASCp � pF1WI, & s3(a - 0WrtC. rcc l —Urovazb� <br /> Coneullant f Suo Canlraclar <br /> DudBk4 ASSoc- Address 6o5 Third S�—CIa cinibasuw Phoney 16D.9�1?•sl l'/ <br /> S9 r O`(" y Iz.l° Icer `� a Township la Ren9e 161, Section 3p <br /> GIs Caordlnales: 7"x .� <br /> WORK TO BE PERFORMED- DESTRUCTION(choose type below) <br /> -g�NEW W HLL/BORING(CPT,GEOPRO <br /> SOIL BORING ADROPUNCH,NAND-AUGER,OTHER-) U OVER-OCRs <br /> U SOILL#�I O PRESSURE GROUT <br /> 'Otho: Grout Speaffcalons: <br /> COMMHrdrs 2L✓tn...cLr 6Y-�. S r'" <br /> TYPEOF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS d <br /> �l.ONITORING �'y-10LLOW STEM GIA.OF BOREHOLE Ori MULTIPLE CASINGS?13 YES )LND WELL CASING DIA; ltl <br /> U EXTRACTION 1]AIR HAMMERCRIVEN CASING TH ICKNESS TYPE OF CASING: USTEEL )PVC (]OTHER: <br /> U VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 5'5 r TREMIE TYPE TO SE USED: 0 AUGERS )k+fosE <br /> Q AIR SPARGE p PUSH POINT <br /> GROUT SEAL PUMPED: )KYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> q SOIL GORING U HANE AUGER GROUTSP <br /> APPROX. DEPTH I -f� t a 17 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> OTHER <br /> CONDUCTOR CASING PROPOSED? KI- (If YES.Ilsl specifications here): <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS, <br /> CALL THE UNIT IV INSPECTOR 4B WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Signed TlaComQany E+�Vitartmt 1l Dudek AGso� <br /> Nnt Name 6{thn0. Iy{�tlal7ory <br /> DEPARTMENT USE•ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS, <br /> WORK PLAN DATED/: I n <br /> Appriration Aceepted BY 7�` '"`r'�"V Date Issued 1q 6 roe°Z <br /> _Final lnspedlon By '� <br /> Grout Inspection <br /> Destruction InsDeclon By ' Date <br /> COMMENTS/CONDITIONS' tlt s <br /> ACCOUNTINGONLYI AID# CAP» <br /> PE CODES FET:INFO AMOUNTREMITTEO CHECKS RE BY DATE PERMITlSERVICEREOUESTii INVOICir <br /> 2-F.bl �4- SqOS�4Zl �� ?/f9��Z. SRit ®��R3-07j <br /> C-57_ WC -WAIVER_ C-57 Letter of Authorization to sign permit`Encroachment doh_ <br /> _ 1/25/02 <br />