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OCT 08 2004 3: 17PM HI.�._HSERJET 3200 COPITp• 2 <br /> ser:av rA 02 <br /> � � zo San Joaquin County FILE. uu■ Y <br /> k; ' +f(`•'; _ Environmental Health Department SITE <br /> K"!' ,.- r 1 304 East Weber Atnnue,3rd rlcor,Stockton,CA 95202 MITIGATION <br /> �\` T" """'"•nf/ (209)468-3449 Fax:(209)468-3433 Web:www.djgov.org/ehd UNIT IV <br /> Well Permit Applicatlon <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROMDATE ISSUED -- <br /> Appllouon k hereby made to San Joaquin County for a PerrNl to construct and/er Install the work desubed. TNs eppQc Uon is made in complisn wllh San <br /> Joaquin County Development Title.Chapter 9-1117.3 and the SfarAards of San Joaquin County Errvimma:ntal Heaah Depanment. <br /> l3�So EAST HW)! 4 So M,+ STocKTA /_� Aareaawa ee'' <br /> WELL Location Crude Svaet NO Clly ZIp%� 1� Parcela 0.D-1¢D-08, <br /> PROPERTY <br /> SM <br /> Owner /S�pR/NE2S <br /> Address SO 177e'. H�WyYI{�7ei�ty oeKrOA( zlzj 5221..y� han <br /> ,c0,2o 1W_ <br /> /]�gcs�l <br /> C-ST Contractor l=.lPgoreaa q�i7� tllY.�l�N 1`'�1Ciy �L�Ytlt �1-(✓�[� �honeS `�ZJ ���-�.CkJLJ <br /> Concuibn /sub Cnir L CE" Adpnal S00 f}I�S%•S�rclrywoo /aJl Phona�s30- (�7�-0 0 9 <br /> OIs Coordinates:X �' Y Townsnip IN Range i5 E Seetlpn <br /> WORK TO BE PgacPRML6-� <br /> (NEW WELL tdORIN CPT,GEOPROSE,HYDR(JPUNCH,HANDAUGER,OTHER') DESTRUCTION <br /> IA O (choose type below) <br /> 3SOILBORINGVER-BORE. DIAMETER <br /> 3 WFU.* I&RESSURE GROUT <br /> XOthar GROUT SPECIFICATIONS NEF37 <br /> COMMENTS: <br /> TYPE Of WELL INSTALLATION TYP& CON$ CT P CI CATIONS <br /> x"ONITORING D HOLLOW STEM DIA.OF BOREHOLEn.a MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION 3 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL 3 PVC 3 OTHER: <br /> D VAPOR 3 MUD ROTARY DEPTH OF GROUT SEAL I O' ZO TREMIE TYPE TO BE USED: D AUGERS giosE - <br /> D AIR SPARGE/OZONE )t11USH POINT(GP orCPT)GROUT SEAL PUMPED; ) Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 3 SOIL BORING DHAND AUGER GROilT SPECIFICATIONS L4W—_ GEME/)" — <br /> R'bTHER'l Pr 3 OTHER APPROX.BORING DEPTH M10-ZZO D BOLTED TRAFFIC COX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED-To-(if VES.fist•pacpFr m in comment section) <br /> COMMENTS: GPT %jORCPIOGES.(Af�f'120� ID) RFN6I/t/G IN DFPTW GRDM 16e-ZZO 1 . <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 4E 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 /> Courity�lnancesjqufies <br /> and Regulations,and all applicable California Stale Lawns. <br /> slpned z�^ `^ ^-^-A-X ti---.^'Ys�.„•�� TNWCamprny � � `1! "')C r"'”" ' <br /> Date <br /> cxx- <br /> DEPARTMENT USE ONLY Q <br /> SITE MAP IN UNIT IV FILE,ADDRESS: Q <br /> WORK PLAN DATED: <br /> Application Accapled By Dale Issued /0 —h� \�N <br /> Grout Inspection BY We FInaI Inspection By <br /> Destrualon inspection Bpinspection Late <br /> COMMENTS I CONDITIONS: <br /> ACCCUNTING ONLY: AIDS FACIA <br /> PE COOE3 FEE INFO AMOUNT REMITTED cHECIf0 REQDBY DATE PERMIT/SERVICE REQUEST a INVOICE <br /> 2401 10-IZ SR# 00 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorizat on to sign permit 49 Erlcroachrru t doe <br /> ERD z9-oz-rot <br /> 6n-'roa \ <br /> V // <br /> l <br />