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1-0!20/2005 08 45 2094683433 EHD PAGE 03 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Ploor,Stockton,CA 95202 MITIGATION <br /> (209)4683449 Fax: (209)468-3433 Web-www.sjgpv.org/chd UNIT IV <br /> Well Permit Application 2005 OCT 19 Ahs 10: 36 <br /> HON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DAT§ A U U 1,4 C 0 U1114 V Via, <br /> Applicallan Is hereby made to San Jo3s(tbn County for a penult to wnubmrt andlor Install th0 work made at=mpbanoe with San <br /> gl. County Development TWe, Z <br /> Chapter 8 7915 3 and the Standards et Sen Joaquin County j� /Z <br /> o-Cae>on tS5 Street J Clty �3YCU�K�I`! 1p���r <br /> PROPER � <br /> Owner <br /> ddress i f�*f^ + A (•�rrK/ Phone# 747 3�C <br /> 0.57 Qmlradw `. dress y _��' &L C+tY�Ip f egj:ba#, <br /> Consultant/Sub Cntr A.U.A Address Gl7 l&ll1-- +Sk ty, c*-9jjfhone9 <br /> GIS Coordinates,X Y ,Township kwVe Sacbor <br /> RK TO Br.P <br /> EW WELL/ CP'T,r.EoPROBE,HYDRopuNCH,HAND-AUGER,OTHERI) Q DESTRUCTION (choose type below) <br /> �# O# 0 W <br /> OVER-80RE d .METER <br /> OffliO-Olhor. 11 PRESSURE GROUT <br /> {�+pp GROUT SPECIFICATIONS <br /> COMMENTS e o r O'Yr�St (I�.. C.twF-/` ex 5S Cmc. •-. <br /> TYPe OR I+IIELL 1NSTALLATIOIJ TYPE SONSTRUCTIDN SPE CATIONS <br /> 0 MONI1'ONNG 0 HOLLOW STEM DIA OF BOREHOLE_ t1 MULTIPLE CASINGS 0 MULTI-LEVE. WELL CASING DFA <br /> Q EXTRACTION 0 AJR HAhIIMERIMIV©d CASING THICKNESS TYPE OF CASING 0 STEEL Il PVC, 0 OTHER. <br /> 0 VAPOR II MUD ROTARY cmzpm OF GROUT SEAL �c TREMIE TYPE TO BE USED MUG RS HOSE S `� <br /> SPARGFJ OZONE VUSH POINT(GP Tg ROUT SEAL PUMPED s ti No (NOT :MAXITML <br /> FREE-FA L DEPTH IS 30, <br /> An <br /> L BORING 9 HAND AUGER GROUT SPECIFICATIONS � C <br /> 1:1 OTHER APPROX-BOPJNG DEPTH� LVc• 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> {� CONDUCTOR CASING PROPOSED (IfL� <br /> Y S,115t spedBcallons In ce ent eedlon) <br /> CO71tINENT3.— 1�1 �G.� � �/ a✓ � <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMI'T'S. <br /> 46 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I Hereby certify that I have prepared this application and that the worst will be done in accordance with Sart Joaquin <br /> County Ordinances Rules and Bpqulaftns,an II a 11eable California State Laws.low- <br /> ��++ <br /> Signed T cry �- 1�+.i� 'z <br /> P tr.�4 C'�' • ��.-t� Dale �f� �^ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILr=,ADDRESS: &2 0 1- CWasi <br /> WORK PLAN DATED:�� 31 2 <br /> Application Accepted By. t2_;r a 2t A. ` A d�&.--4�Yt __Date Issued 1 D - a <br /> Grout Imspacbon By Date f=inal Inspec4on By Dale <br /> Destn ctort Inspection By Date <br /> COMMEWS 1 CONDITIONS - <br /> ACCOUNTING ONLY All* FAC& <br /> PE CODES FEZ INFO AMOUNTREINPrTED CHECK# RXC'QBY DATE PERMIT ISERVICE l2EDUEST# INVOICE <br /> o !G / SRO 0d 450 <br /> WCC WAIVER C-57 Letter of Au thonzatlon to sign permit encroachment doc-_ <br /> OW 29.02.001 <br /> 614104 <br />