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10/20/2005 08.45 2994683433 EHD PAGE 02 <br /> • San Joaquin County <br /> Environmental Health Department SITE <br /> 304 Fast Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)466-3449 Fox (209)468-3433 Web:www sigov oaf ehd - UNIT IV <br /> Well Permit Application 205-OCT 19 Alf la 37-._ -- <br /> NOW REFUNDABLE PERMIT I=xPIRES 7 YEAR FROM DATLAi ��'0 U1N! C 0 U11 T Y <br /> iR0A1F <br /> Appiluden Jr.hereby made to San Joaquin County for a permit to construct and/or Install the work d"ff0VT Ir �� campy with San <br /> Joaquin County Development Trite,Chapter 8-1116 3 and the Standamlo of San Joaquin County Effidronmentat i& <br /> 1;1 canon 6 20 c f-v4mm st ee, ,� , -�1�,a �a <br /> P ECJ t c� � $ �Rda Yt�. W. ,�' �utr�°"�' t, /o <br /> cltyy - _ Pfwrie C > &6S-t7Zs1 <br /> C-57 Contractor r „J�ddZddress <br /> 1r2 (L,- - A-A city s•�•� fT�lp dJ�uc# Pg4tona# 3/3 S`$G0 <br /> ConsultantISubCntr Cnnti6 yfeogoy'-S.st sLe G[y � wIL. 4dt � -iL PhvrteiC p� x'33 �{ <br /> GIS Coordinates % ,Y Townshlp Ranga Soc*on <br /> VIfORx TO IM"a <br /> NEW WELL/ CPr,GEOP OBE HYI�I3,OPUNCH.HANGAUGEFt OTHEFn tl I)ESTRUCTION (choose type below) <br /> ' SAIL BORING� PT t L (may 0 OVER-BORE. DIAMETER <br /> aVXI.LiC Q PRESSURE GROUT <br /> Il-Other GROUT SPECIFICATIONS <br /> COMMENTS_Q5-*-� 1.A14-t,.—. .. . . <br /> TYPE OF WEt.L INSTALLATION TYPE CONS ON POI G FONT <br /> II MONMORING o HOLLOW-STEM DtA-OF BOREHOLE—&L!1' li MULT]PLE CASINGS a MULTI-LEVEL WELL,CA$ING DIA <br /> [l EXTRA"ON 0 AIR HAMMERIDRrYEN CASING THICKNESS TYPE OF CASING G STEEL 0 PVC I]OTHER. <br /> [l VAPOR o MUD ROTARY DEPTH OF GROUT SFAd e�F& e TREMIE TYPE TO BE USED- f fALMGERS HOSE 5 <br /> SPARGE!OZONI4*Us"PONT(GP 16aGROUT SEAL PUMPED:X�L � <br /> (NOTE:MAXIMUM FSE-t;AI..,�DEPTH 1S 30') <br /> tL BORLNG [I HAND AUGER GROUT SPEGtI=ICATION3 �t N�a. f'- n.-1� .�� t I <br /> Q OTHER OTR APPROX BORING DEPT Q BOLTED'TRAFFIC 805i or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (3f YES,fist gmcfficadons In comawnt sedron) <br /> COMMENTS G( 'i � -a x c GPI"-- /6 <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 Sar:Joaquin <br /> County Ordinan ,Rules and RegUlado ,Vail applicable California State Laws_ <br /> Sigrredx1. TrtlelCompany r" c�C �S _� r`"t_ <br /> v -g_ I to t �-/ v <br /> P Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNrT IV RLE,ADDRESS; .6zy W P S t___ aa e f-&Y- W'a V ` <br /> WORK PLAN DATED; A a <br /> e ) 2 <br /> Application Aooepfsd By i L rider Date Issued 10-td? -05- _Area t S1 <br /> Grout tnapecbun ey. date F-FnW IngmcCon By gate <br /> Destrucgon Ins on 13Y Dame <br /> COMMENTSICONDMONSs - " t <br /> ACCOMMNO ONLY AIRi FACt <br /> PE CODES FTSE INFO AMOUNT REIRITTEDLCHECK 9 RECD BY 0ATE PERMIT I SERVICE REQUEST* INVOICE <br /> gal Rio / SR# <br /> W_ WC-WAIVER C-5I Letter of Authorization to sign permit Encroachment doe.,_,_„ <br /> 29-02-001 <br />