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, <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 Fast Weber Avenue,3rd Floor,Stockton,CA 95202 MITIGATION <br /> • (209)468-3449 Fax:(209)468-3433 Web www sjgov.org/ehd - UNIT IV <br /> Well Permit Application 2005 OCT 19 Am til: 36 <br /> NOH-REFUNDABLE PERART EXPIRES 4 YEAR FROM 13ATIE IS5*11114 J 0 d u U I H C 0 U N T Y <br /> Application is hereby made to San Joaquin coup ivr a pwmt to connect andlor m a tan theme des cr F appp�ip� EJ TT mplanee wilt+Sect <br /> Joaquin Cody OevetopmentTifle,Chapter 3-0145 3 and the Standards of San Joa uln Co Ernolrotvn -ILEI ! [ t <br /> �on � W Ci Vice T—Cm�.,�s SbWt Cabs �- p QZ at�pA m IJ fj' <br /> PROPtR�4 <br /> Cwner L th A ,,l C. ��D11lAddress -Z() u1 ar 4ec_ CRY�1VLIp phone# iZOgl 9� - O � <br /> m67 Corttrector dress,9Zu Mt& -1" Cigr kZ p� LIc1F hu}iTe 2 5n 313 SYOD <br /> COnsuMntISub Cntr - dress tom_ �eC�i 5'�- caty _uax -`W7pt,ane C_ ) <br /> GIS Coordinates x Y T~sNp RarWe Seaton <br /> OS E ' <br /> EW WELL OP;0 <br /> (CPr.GEOPROSE HYDROPUNCH,t ND-AVGER.OTHEW) p DESTRUCTION (choose tym below) <br /> a SOIL BO � I$ 1Z a OVER-BORE DIAMETER <br /> LI WELL S [I PRESSURE GROUT <br /> p*Other GROUT SPECIFICATIONS <br /> C70AlImiEIVT S N L ;au Pc POW—5-ee- <br /> 71CFE OF WELL tNSTALL.OTIOAt Ir (:ONS7'g17CTiON SPWFIC_AT_IONS <br /> p MONITORING 12 HOLLOW STEAK DLL OF BOREHOLE 3 fI U MUL71FLE CASINGS Q MiULTFLEVEL WELL CASING DIA, <br /> p nCrRACTION d AIR HAMMFRIDRIVEN CASING THICKNESS— yTYPE OF CASING 0 STEEL_ 11 PVC L1 OTHFA <br /> APOR B MUD ROTARY DEPTH OF GROUT SEAQ dO 1 e yq REMtIE TYPE TO BE USED- AUGERS r—URME—i7'�d s <br /> SPARG&OZONE AUSHPOINT(GP orC "jGROUTZEALPUMPE ,)Yes (N <br /> allo OTE•MAXIMUM FREE-FALL DEPTH IS 309] <br /> OIL BORING [I HAND AUGER GROUTSPECIFICATIONS <br /> 0 OTHER]OTHER APPROX.BORING DEPTw 3 t04 t Q WW1]BOLTED TRAFFIC BOX or p STOVE PIPE <br /> GONDL�TOR CASING PROPOSED_ YID,fist spe Meations in comment secbon) <br /> COMMaRM. 12 a _kpo l711_I.m ' ---- - <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORIUNQ HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby cerbfy that I have prepared this application and that the work Will be done In accordance with San Joaquin <br /> CounIty Ordinan es,Rules and Reg tion anti all s cable Canfornla State Laws. <br /> 01 <br /> Stgrted Td[elCompany nt .� C��'�� rti� <br /> cite <br /> OEPAWMENT USE 0NLY <br /> SITE MAP IN UNIT W FILE,ADDRESS: le 2 D 19 e:S _Hrjr•�-�- �/1/d v __ __ <br /> WORK PLAN DATED:_ Aij a tt s t 31t,,20P 5._ _. <br /> Applleabon Ampted ftV i�.�A r i A lYt e-CA. Date issued - Aw s <br /> Grout Inspection 13 Dale Final Inspeetim By Date <br /> Desttucim Inspection BY Data ��J <br /> COMMEWMICONDnTONS• 1 7 <br /> ACCOUNTING ONLY AIDE! FAC* <br /> PE CODES FEE INFO AAROUMr RFMnTED CIiECK S KEC'D BY DATE PEMT I SERVICE REQUEST 0 INVOICE <br /> g 91 I G d s <br /> 7 WC-WAIVeR_ C-57 Letter of Authorization to Sign permit Encroachment doc - <br /> ERD 294"01 <br /> V22104 <br />