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Oy10/19/2004 10:29 FAX � V 1 <br /> San. Joaquin County v <br /> Environm(tntal Health Department 2 OCTq 0 2006 <br /> SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202 QG+ MITIGATION�'�''"� <br /> (209)468-3449 Fax: (209)468-3433 Web:www.sjgov.or91614hc}IRONMENT HEALTtINIT IV �or.�--- <br /> Well Permit Application PERMITISERYCFO' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in oomprmnoe with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and tho Standards of San Joaquin County Environmental Health Department. <br /> r,� D {�,,,�,/ Crws Street O Owl0. y d'D✓i Zip /SZI S Pa,w I g 3-I`(0 0 <br /> WELL Location N e- C 111 S o E •"' { LI Cil �a C r <br /> PROPS (� OO 1n( ('\ ISZ.I PhoneY�0 `-0' - 009 <br /> Owner CAOW .So ltJ'a Atldff <br /> ress 11 y S 1 O`l a' " '•, ,QCity�'CD�Z� c-� <br /> C-57 Contracto Address QED )"TD -t- '�&ily �P�)� 0`7o <br /> Sub CnU neit�TT X313-J� <br /> („SSC Address5OG '�tr>r CltyWOa 10AIGN Phon- .5SO-i 61-UIoQ <br /> ansultan / - 21 E Z.r r� <br /> GIS Coordinates:X - ,Township Township--Lm Range E Section r LI7 <br /> WORK TO BE PERFORMED: <br /> .$NEW WELL! O (CPT,GEOPROBE,HYDF:OPUNCH,HAND-AUGER,OTHER') p;DESTRUCTION (choose type below) <br /> 0 SOIL BORINGS 0 OVERBORE. DIAMETER <br /> ;XPRESSURE GROUT <br /> 0 WELL 0 or GROUT SPECFCATIONS MF+� «✓h&rL7- <br /> 0a'Other J <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE COIJSTRUCTION SPECIFICATIONS <br /> "ON(TORING I]HOLLOW STEM DIA.OF BOREHOLE 7_• 13 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DW-ti-14 <br /> [I <br /> IA: t - <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS_±LA _TYPE OF CASING: 17 STEEL O PVC 0 OTHER: <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 11,0--L7-0 TREMIE TYPE TO BE USED: 0 AUGERS JWOSE <br /> 0 AIR SPARGE/OZONE jVpUSH POINT(GP or CPT)GROUT SEAL PUMPED: Pes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0SOIL BORING 0HAND AUGER GROUTSPECIFCATIONS t4ey�+ tt<rNt^+ <br /> QtOTHER: C PT 0 OTHER APPROX.BORING DEPTH JJoO^2--0 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTQR CASING PROPOSEDI(If YES,I{st specifications in comment section) <br /> COMMENTS: CPT dur ` PRO • uu7L-//l1 rA1V AII/'1-1+ ASM I�0 ^2Z0 <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 ina e , Rules and Regul ns,and all applicable California State Laws. <br /> r .. T(tle/Compart <br /> Signed x <br /> Print Name `r <br /> DEPARTMENT USE ONLY <br /> C'l C J�,_ �6�Ctiir4craaP <br /> SITE MAP IN UNIT IV FILE,ADDRESS: d v C <br /> WORK PLAN DATED- cc, <br /> /'f7 -2-O Area�6 <br /> Application Accepted By Dale Issued ate <br /> Grout Inspection By Date Final Inspaction By <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID* F <br /> PE CODES FEE INFO AMOUNTREMITTED CHI2CK 0 RECD BY DATE PERMIT l SERVICE REQUEST S INVOICE <br /> Z.fo l _( � 9-t3 (o Cid IaZa� SR# X05 <br /> C-57 WC�,/-WAIVER_ C-57 Letter of Authorization to sign permit_Enc c ent do <br /> EHD 29-02-001 r <br /> 627104 <br /> -- - - .. uep Telr{ R..IeW eoe : Ti 11,0 61 100 <br /> T •cl STLSETESZ6 <br />