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WELL , ,ERMIT APPLICATION FORIvv� ) cJ LOP & SITE <br /> SAN JOAQUIN COUNTY nJ� If�ITIGATION. <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) _`J' UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-34499 2U04 <br /> I NON-REFU D LE PER IT EXPIRES YE FROM DATE ISSUED -�(G 1':• <br /> A <br /> pp ICadon IS hereby made to San Joaquin County for a permit to construct and/or install the W06 described. This appiiCa[rf�i1•'is rfYa�de in QpfL>(�IlanCe with San <br /> Joaquin County Development Tule,Chapter X1115.3 and the Standards of San Joaquin County Environmental Health Departmerlt`';14 t "< <br /> d _ A's <br /> WELL Location sessbrs <br /> 103-10 G45T INC- 9MEET Goss Street of AINSf•City l�t�i Zip b2 Parcel# Q�0-07—((2 <br /> PROPERTY Owtler Lf}I_ f(Twq� Address 30o in�STA�62 � City LoDI Zip q 5-2-42-Phone#(209J 369- 262 <br /> C-S7 ContractorLAYGi/ZiSiENCN (C, Address qi ACiQQT oip 233 Lick 5 idC 11 Phone# D 10-2 3 <br /> Consultant/Sub Cntr EZC pEMWIRprJ 3 <br /> Addres6 53Do i/t(C(rdHNrltE diQISiE/OiClry rr19r-ERfFfEDLic# Phone# i�31-�906 <br /> GIS Coordinates.X Y Township Range Section <br /> WORK TO BE PERFORMED; <br /> )(NEW WELL/BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER-) []DESTRUCTION (choose type below) <br /> p SOIL BORING# <br /> Q OVERBORE. DIAMETER <br /> ',WELL#N_A-G�AR[,E A,�o I r eiL✓000 L C Ac?-10iISVE) 0 PRESSURE GROUT <br /> O'Other GROUT SPECIFICATIONS <br /> COMMENTS:_5Ecp-rr7 C[ �tGun��s ro3Fo wELt txcRslo/�S AMID fiauleo 710 /Wo 9 R� SyEAzvo �QSpg�, u�_ <br /> o SEC EL <br /> TYPE OF WELL INSTALLATION TYPE CbNSTRUCTION SPECIFICATIONS <br /> 0 MONITORING HOLLOW STEM DIA.OF BOREHOLE`�r� 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS Z�-0 IA.�SicH• DOF CASING: U STEEL PVC Q OTHER: C� <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL _ TREMIE TYPE TO BE USED: p AUGERS )(HOSE/PVC <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: XYes a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS rT-ctigic W v 5 "r►E OWDER . <br /> 0 OTHER: rt OTHER APPROX.BORING DEPTH ' , 0 jjBOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED_(if YES,list specifications in Comment section) y <br /> COMMENTS: f}cCESS A469EM15WT WILL ISE AcQytIZo2P PEER Tu /NsTALun14 WELLS <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 4 <br /> County Ordinances, Rules and Regulations,and all applicable California State Laws. <br /> Signed x 'l/l/• TitleiCompany 5EX10r, 6EU-CfilS—i EzC P_EMQ>If1i-0a ' <br /> Print Name !2 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: � (� <br /> Application Accepted Date Issued 11404/ Afea� <br /> Grout Inspection By Date U Final Inspection By Date <br /> Destruction Inzpection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY. AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST R INVOICE <br /> FQ" 8`56 t�L L // Zq o SR# pa b <br /> C-57_ WC`-WAIVER C-57 Letter of Authorization to Sign p rrnit_Encroachment doc` 9/30/02 <br />