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Zb/10/2984 15.37 2094663433 FIFTH FLOOR PAGE 02 <br /> ' <br /> HorFC L V1�� WELL PERMIT APPLICATION �o�M SITE <br /> MAY 0 5 2004SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> ONVIRONNIENT HEALTH 304 E.Weber, Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE YERLMIT EXPIRES s YEAR FROM PATE ISSUE <br /> kWicabon is hereby made to San Joaquin County for a permit to construct andlor qutatl the work described This applicabon is made in compliance wiih San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department r� <br /> rc / Assessors f� r <br /> WELL Location CtiC� f r IJa Cross Street i C ty 516c k4on Zap PaToeW <br /> PROPF�. 7: A Vna�dl.a..iflol�a�N4lr'`A�ari.t <br /> Owner Address 21 1 fz ���� Q!"a+� Gty Laj' Z,p?32Yo Phony#(7a4-) `IfI3 -d 11c Y <br /> C157 ContractorG2�13_()r~11"'I a-,d L' <br /> Address 9a bl'�ve Crit a� 2op 9�'gm,c# -Yb'S165 PttiortelF 2 5'x!3-Sko <br /> L■/ <br /> Cotuultant r Sub Cnlr�«�C�,L I-C Address ?-70✓reke s_S f.c i_City&! .a UCA Phone# 07-1r 3 -Z3 69 <br /> GIS Coordinates_X Y Township Range Section_,., <br /> WORK TO BE PERFORMED <br /> Q NEW WELL 1 BORINGP GEOPROBE,HYDROPUNCH,HAND-AUGER„OTHER) p DESTRUCTION (choose type below) <br /> $SOIL BORING# S 13—9 S -� SP-�r5g-`� p OVER-BORE DIAMETER <br /> vELL# D PRESSURE GROUT <br /> II'Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUC"RON SPECIFICATI NS r� <br /> MONITORING HOLLOW STEM DIA OF BOREHOLES �11 ht LTIPLE CASINGS 11 MULTI-LEVEL_ WELL CASING DIA. Z <br /> r LPr Lor•S, <br /> U EXTRACTION 0 AIR HAMMERORNEN CASING THICKNESS s�TYPE OF CASING Q STEEL PVC []OTHER <br /> ��R I1 MUD ROTARY DEPTH OF GROUT SEAL 3 TREMIE TYPE TO BE USED ]AUGERS HOSE <br /> pWSPARGE!OZONE,�BPUSH POINT(GP r GROUT SEAL.PUMPED xYes 1]No (NOTE NMAXIMUM FREE-FALL.DEPTH 15 30`) <br /> 0 SOIL BORING a HAND AUGER GROUT SPECIFICATIONS J00 14-1—J AZr c c,�g.- - <br /> OTHER it OTHER APPROX BORING DEPTH SQ/ &toLTED TRAFFIC BOX or 13 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED /v-/0 (if YES,list spedficatcons in comment secWn) <br /> COMMENTS :� a <br /> NOTE: OFFS! 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 Ordinal ! and Reaulations, and all applicable Calrfomia State Laws. <br /> Signed z TctlelCompany cair <br /> - <br /> Print Name �►�'!fi Dale ~� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accept id By Date Issued Q �a Area <br /> Grout lnspecbon a r Date Fina!inspecton By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AIDN FAC+F <br /> ODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA PERMIT I SERVICE REQUEST# INVOICE <br /> Qq 3 -7-g 5 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to gn er It Encroachment dot 9/30/02 <br /> t <br />