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' 09123/2004 11 15 2094583433 FIFTH FLOOR <br /> PAGE [32 <br /> l I IT C [OJ) <br /> EY <br /> t WELL PERMIT APPLIC I SITE <br /> I ©© <br /> SAN ,fOAQUIN COUNTY PUBLIC HEALTH SERVICES MITIGATION <br /> u�IT�-V ---. -- <br />' r SEP 1 '7 2004 ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 F. Weber, Third Floor, Stockton, CA., 95202 <br /> y� �y; � ►-I (209) 468-3449 C)�\j <br /> NON-REFUNDABLE PERMIT EXPIRES_ YEAR t~FROM DATE 145Us i3 <br /> Application IS hereby made to San Joaquin County for a permit to Canstruet andlor install the work descntnd Tbis application is made in compliance with San <br /> Joaquin County Development Title Chapter 9 1115 3 and the Standards of 5an Joaquin County Pubbc Healtl-,Serv1aes F-11111111111`15111111 Health bivrslon <br /> ' Assessoz's <br /> WELL Locatia � Cross Street k' City �G Zip ���y Panel# ld^ l� <br /> PROPFRTYOwner ldtSfP /Cd✓laca�lcll�, s Address I ra JAY Caty cfn Zlpd`do Phvne# <br /> �,------- _ rte,, <br /> C-57 Contractof �th r �4ddrEsS� tzt � ' # City kt Zlp 7+}?�Lich / Q-Phone# <br /> Consultant ISub ContractorQ <br /> C,1S Coordinates X ,Y__, / —,Township _ Cv Range Section .f/� <br /> WORK TO BE PERFORMED <br /> NEW WELL I BORING(CPT GEOPROBE HYDROPUNCH HAND-AUGER,OTHER-) <br /> Q DESTRUCTION(choose We below) <br /> d SOIL BONING-4 a OVER-BORE <br /> WELL# — 7 Q PRESSURE,GROUT <br /> 'Other Grout Specifications <br /> COMMENTS �� Cf f� [(( s�k-ll� ; 'r i <br /> TYPE QF WELL INST LLATIQN TYPE COIJSTRUCTION SPF,CIFICATIONS <br /> MONITORING a HOLLOW STEM DIA OF BOREHOLF-10L MULTIPLE CASINGS)n YES (I NO WELL CASING DIA L <br /> a EXTRACTION H�AIR HAMMERIDRIVEN CASING 7HIGKNESS_Zj(],_TYPE OF CASING U STEEL ,KPVC 0 OTHER �Y— <br /> VAPOR a MUD ROTARY DEPTH OF GROUT SEALjQ:: n _ TFREMIE TYPE TO BE USED !]AUGERS ,{THOSE <br /> ' AIR SPARGE tj PUSH POINT GRCUT SEAL PUMPFO aYes p No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING t]HAND AUGER GROUT SPECIFICATIONSe—' f'- — <br /> a OTHER tl OTHER,_,__ APPROX BORING DEPTH 12jb • AB0LTE0 TRAFFIC BOX or 0 WOVE PIPE <br /> C� cON17UCTOFR CASING PROPOSED?__(tf YES,IFSt spesxfioationS dere) <br /> "COMMENTS: r'inn 1 L bwE As. (26" V ' h{ ` <br /> .67-0'r c.dc.t"1 00 -ax — ry p <br /> NOTE' OFFSITE 130RINGS REQUIRE ACCESS ORE CROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done in aoeordanCe with San Joaquin <br /> County Ordinances, Rules nd Regulations,and all applicable California State taws <br /> S9nedx Title/Company -p_ ccf 5'c. 7s+�, LQ� -,+��+-YsoT►�.sc�`— <br /> �� <br /> Print Nern Date <br /> DEPARTMENT USE ONLY <br /> sgy <br /> SITE MAP IN UNIT IV FILE,ADDRESS: `' <br /> ' WORK PLAN DATED: 4 <br /> V Date Issued_,.! <br /> ' Application Accepted By — — <br /> Grout Inspection sY Dale Fnal Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CQNDITIONSt <br /> ACCOUNTING ONLY AID# <br /> WC-57— <br /> FEE INFO AMOUNT REMITTED CHECKS REC'Q BY PATE PLRREQUEST# INVOICE <br /> 1/1� � rt/ 'z- <br /> G,.=WAIVER C-57 Letter of Authcrization to sign perinst Encroachment doc N. 9!2710 <br />