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_ 07/01/05 FRI 14:13 FAX 559.2"F 8 SECOR <br /> X002 <br /> 07/01/2005 13:55 2098EHD FI��MU S <br /> PAGE D'1 <br /> San Joaquin County <br /> Environmental Health Department "o F-Cy� <br /> 304 East Weber Avenue,3rd Floor, Stoddart,CA 95202 daON <br /> ' (209)465-3449 Fax: (209)468-3433 Web:www,sjgov.org/oU JUN 3 0 k"T IV <br /> Well Permit Application NT HEALTH <br /> NON4WIFUNDABLE PERMIT EXPIRES 1 YCAR FROM DATE ISSUED pFRM1Tf SERVICES. <br /> Applleation Is hereby made in San Joaquin Co"for a permit to mnebuM and/or Neoall the nark desafled, Thio application IF made in compHanco with San <br /> Joaquln Counly Developrrlont Tele,Chapter B-1115.3 and the Standards of Son Jo tguin County Environmental Health Depertmem_ <br /> Aaaess xs <br /> WELLLocation 508 4'barter Way cress strea(LinCOlt1 CIMS tOOIStonyrp Palrsl# ((�� 040/1c <br /> PROPERTY / <br /> Owner' llxj:nder Saini d,esr:506 W ,Longview D3yjtocktonZIP95207phonatt <br /> CSTeernraeter Precision Address? n$1 Faepv A, cl2�,iChenon131ip 948Q11� 6 6'3 nema;C:51 0 237-4575 <br /> Caneulent/sub Cnlr SECOR �gadnss3475 WeS �Yrm riClly Fr.o ^^ # Pnena#1559) 271 -2656 <br /> GIS CoaMinates:X ,Y ,Township Range Secnan <br /> 7NORK TO 6E PC-RF[10MED: <br /> fNEW WELL/BORWG (CPT,GEOPROBE,HYOROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type baloM <br /> E SOIL BORING u9 dir®Ct U ROVER-BORE. DIAMETER <br /> 0 WELL# / 0 PRESSURE GROUT <br /> r�Gr2S.P2' t•� V m I II O GROUT SPECIFICATIONS <br /> o <br /> COMMENTS:Ttal dnnth at 1r et-66 f+ <br /> TYPE OF WELL IN­!L1AL1-A nON TTPE COMSTRUCTION SPECIFICATIONS <br /> U MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS 0 MULTI-LEVEL WELLCASIN501A:_ <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING; O STEEL O PVC BOTHER, <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED' 0 AUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: d Yes ON. (NOTE: M"IMUM FREE-FALL DEPTH IS 30') <br /> ASOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH Ei S FT O BOLTED TRAFFIC BOX or O STOVE PIPE <br /> COMMENTS! - <br /> CONDUCTOR CASING PROPOSE07 f I/Of /j7�(II YES,lost gpecMaatione ih comment eartion) <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify that I 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 a_�a�. •7- Tille/Company. Staff Geologigt <br /> Print Nam_aR'4 TConan _ Dated,f'g /n F <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV PILE,ADDRESS: �� r -( <br /> WORK PLAN DATED: A O r iF21 <br /> APplieaton Aompred By V I e.+vr 1,a L. M eco tneu Date Issued J u S 2005' II sem. <br /> Grout Inept BY fy,Dace ') / InspaQion 9y "^ atP�„•_Gj;�'D <br /> Deslructlon Inepedon Or Data <br /> COMMENTS/CONDITIONS; fe T r' n ,S <br /> ACCOUNTING ONLY: AID# FAC! <br /> PE CODES FEE INFO AMOUNT RLMItTED CHECK# RECO BY DATE PERMIT I SERVICE REQUEST INVOICE <br /> 3SvI g'?. 00 89. 00 -R0 00 +2c?5/ <br /> C-57T WCC WAIVER__ C-57 Letter of Authorization to Sign Permit—EncronChment dee_ <br /> EMP 29-02.001 <br /> &Q210A <br />