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01/27/2005 10 08 2094683433 FIFTH FLOOR PAGE 02 <br /> I� �' San Joaquin Coun <br /> ,Q F � q tY <br /> " a <br /> 64 <br /> Environmental Healtb Department SITE <br /> { 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 MITIGATION <br /> (209)468-3449 Fax (209)465-3433 Web www sjgov otglehd UNIT IV <br /> Well Permit Application O <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED <br /> Appilcat=Is hereby made to San Joaquin County for a perma to construct and/or instaif th(�work described This apphcatlon Is made in compliance with Ban <br /> Joaquin Gou-ity Deveiopmort Tale Chaptor 9-1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> nn Assessors <br /> ' <br /> gross Street kr <br /> WELL Location 15 � '-j j I b)'p �c c�' city C rL a;7.._Zip C` Parcell <br /> PROPERTY p 11 <br /> 0%yruar._ an4c.a PL, II�'�5 Address 3p7� 1., 1(-6,jApCity Z r.rLZip c72 _Phone# --VA' C 57 Contractor AL l^�0DJOvLL& &Address _S)" D 64.. kk Pzj CityZIp_L off-ZP hone# <br /> a <br /> Consultant 15u5 Cn,r 'c ` +tib Lx��__Address0l�,J srl{ _ C ty Iu R �l �t lc# �✓ Phone#11(a �G�-J lOC <br /> .T <br /> GIS Coordinates X -,fes Y Vlk Township s Range Saotio7 "'VA <br /> ' WORKTQB7_PERFORMED <br /> LKNEW WELL I BORING (GPT GEOPROBE,HYDROPUNCH,HAND,AUGER OTHER') p DESTRUCTION (choose type below) <br /> []SOIL BORING# U OVFR-BORE DIAMETER <br /> ' allrLLn NUJ-Ica 9FRL*SSUREGROUT <br /> Q"Other GROUT SPECIFICATIONS <br /> �7 + t i <br /> COMMENTS Ji S'_tc t+�s�4 PIT.. }`� sJ�C I T _ lc� �C1v. jj 4COL Zz=ta _ <br /> V, <br /> TYPE OF WELL INSTALLATION T�'PE CONSTRUCTION SOEGIFICATIONS - <br /> 4CMONI70RING I] HOLLOW STEM DIA OF BOREHOLE 8" []MULTIPLE CASINGS U MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION ()AIR HAMMERIDRIVEN CASING THICKNESS , L 2-10_TYPE OF CASING p STEEL &PVC 0 OTHER <br /> 1VAPOR Il 111LID ROTARY DEPTH OF GROUT SEALS TREMIE TYPE TO BE USED 0 AUGERS CHOSE <br /> 01,AIR SPARGE!OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED- R Yes 0 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL.BORING 0 HAND AUGER GROUT SPECIFICATIONS J_-/ 4_ <br /> BOTHER_VOT-ERc3+- Cr APPROX L3t7RtNG DEPTH1 7�O60LTED TRAFFIC SOX or 0 970VE PIPE <br /> CONOUCTOR CASING PROPOSED_r 0 (If YES,list spocifications In comment section) <br /> COMMENTS <br /> f l �S .,Q�� i..�'1 sir L-, �i� nJ� t? �7 J.,�rr.r <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 San Joaquin <br /> County OrdrnanVules and alJ appltcable Caitfornla State Laws /Signed x � 7 tlelCampany_ 1zI /��O c- •_ <br /> S f� Date _ I J' <br /> Print iVame ., <br /> ' DEPARTMENT USE NLY f� <br /> SITE MAP IN UNIT IV BILE,ADDi SS' <br /> WORK PLAN DATED <br /> Appllcaoon AccePh;d By Date Issued � � Area <br /> Grout Inspoction B} Date Final inspecban By _ _ Date <br /> Destruction Inspec ion BY Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> PE CODES FC5 INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> t_y SR# � <br /> C-57— WC___-_-WAJVER C-57 Letter of Authorization to sign perrmit� Encrodchment doc A <br /> EI 10�9 02.002 <br /> 6l�2/QL <br />