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08/24/2005 11: 35 2094 33 EHD PAGE 02 <br /> D <br /> • x %+6 \ •L San Joaquin County �. <br /> N%�r�J Pr <br /> ,{ >� Envixonmental Health Department ITE <br /> l`� 304 Fast Webcr Avenue,3rd Floor, Stockton; CA 95202 TI GATT ON <br /> 4 T (209)468-3449 Fax: (209)463-3433 Web: rnvwsjgov.org/ehd AUG 3 2 UNIT IV <br /> Well Permit Application ENVIRONMENT HEA H <br /> NODI-REFUNDABLE P-._ 1 YEAR FROM DAVE ISSUED <br /> PERMIT/SERVICES . <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the wont described. This application is made in cpmpllance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin <br /> { b County Environmental Health DepartmeM. <br /> WELL Location 1�5 IL7 Jf.�tlSe Rr� Cross Street�Gl_Ci r Assessors <br /> ZIP parcel# Zoy 030�p�i <br /> PROPERTY r t <br /> ' Owner. C �oV4y4,t,�,tt IJ-Lgadreaa ?Q I r... Bbd �- <br /> n (T�Cay /a.y, Zia�Phanea o4- 836-156x . <br /> CS7 Contrsdor' Adtlress r O I j I l�11 <br /> --rr City Zip Lica Phone I00 <br /> ' Consultant/Sub Cn4(-ov�I ��oH� I<daJ-✓t• Su. C 'S <br /> Addres I� a P city LKao✓lLictt P. oq <br /> hanea <br /> GIS Coordinates:X -Y Township _Rane <br /> 8 Section <br /> WORK TO BE PERFORMED' <br /> W WELL /.BORING (CPT GEOPP'aB HY ROPU CH,RANO-AUGER,OTHER' <br /> Q SOIL BORING <br /> � P�dr ) -O DESTRUCTION (choose type below). <br /> WELL#�}f..rr y HOVER-BORE. DIAMETER <br /> WWW Q. Otherr/}N_VQ //o ��- F��`'��pC O PRESSURE GROUT <br /> q I ( 1 GROUT SPECIFICATIONS <br /> MMENTS: Wecl� 'i�.r��.�.,GL 1t.V Ft -tlo.a.l fro wr-kr Gay'cs�.It I Dr >` {� �t la ,I� plr� —APi,I I�f Zc <br /> TYPE OF,WELL' INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> • '.` MONITORING AHOLL'OW STEM DIA.OFBOREHOLE y' rr <br /> - 0 MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: 2 <br /> Q EXTRACTION Q AIR HAMMER/ORIVEN CASING THICKNESS 5�-H N D TYPE OF CASING: Q STEEL PVC <br /> 0'VAPOP, Q MUD ROTARY . DEPTH OF GROUT SEAL O OTHER; <br /> TREMIE TYPE TO BE USED; GAUGERS Q HOSE <br /> O AIR 3PARGE,OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No SSNOTE; MAXIMUM FREE-FALL DEPTH.IS 30'I <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS 1 J z <br /> Q-OT}tER Q OTHER APPROX.BORING DEPTH' 17 ' 25 r <br /> p BOLTED TRAFFIC SOX or 'Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED O (if YES,list specifications 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 1 have prepared this application and that the work will bedone in accordancewith San Joaquin <br /> County Ordinances,`Rules and Regulatit rls,:and all appllcaliie California Stafe.laws, <br /> Signed x <br /> '/ Title/ComPenY --etc-'ti co Gt: ott�o/ ^�'{tnn �ic�w �- <br /> Pdnl Name ry- i.i,N <br /> .. - Oats -Z-OS <br /> DEPARTMENT USE ONLY <br /> SITE MAP,IN UNIT IV FILE,ADDR SS: ✓ a <br /> WORK PLAN DATED: ( ��p- vl <br /> Application Accepted By <br /> Grout Inspection By Date Issued Area �1L/ <br /> Date Final Inspection B <br /> Oestructlon Inspection By ala <br /> Date <br /> COMMENTS/CONDITIONS: <br /> W11NITIAIDSFAC#AMOUNTREMITTED CHECK# RECD BY DATE PERMITI SERVICE REQUEST# INVOICE <br /> za33 �,� SR#IVER� C-57 Letter of Authorization to sign Permit Encroachment doc <br /> EHD 29-02.001 <br /> 6!12/04 - <br /> RFCFfVFD T1W Alli, 94 11 . 99AM <br />