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IIALLL n-AUUL AAD Abbuu. ENV DEPT Q002 <br /> 07/21/2006 15:01 2094683, EHD PAGE 02 <br /> p" San Joaquin County, q nC��C�a�C IZ <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor,Stockton,Cts 9516y- 2 X -2006 <br /> (209)468.3449 Faye; (209)468-3433 Wab;www.s' MITIGATION <br /> ' j9E'N"* SENT HEALTH UNIT IV <br /> Well Permit Application PERMIT/SERVICES <br /> NDN-REFUNDABLE PERMIT EXPIRES t yvAR FROM DATE ISSUED <br /> Application Is hereby mode to San Joaquin County for a permit to owstntct and/or Install the work described. This application is made in 9ompllanee with San <br /> Joaquin County Development Title,Chapter 0-1115.3 and the$tenderc�sp(San Joaquin COunlY Environmental Health Department <br /> WELL Location /O SG 0 f �j)+ j �f <br /> •'"Lrossztreet-riv•rotfrw.,ACey-PO frZ1j �sessars <br /> PROF 11Chy zlp Percel# /?.3`Z 745 -02 <br /> Owner rww:-/� r—"V4n--.!ftddrass /&Slop r-ri✓1sd-rA'J( `!std <br /> C�47 Comraotor_ V .W 1Aj ity C"~/ 2 p ,Phone# ZO s�2 gFsp <br /> ��s rA+ Ie,,,-?0 ReK ��(e <br /> Consultant/Sub Cntr�w i'lwec kvl j gfr+4 Clty�rrc p9S4'���#C Phone# 7f V 61 v <br /> Address?oSd �,..r..t�.•�r Clty W. !'TMC Llckk Phone# fie- 3�2 rye f <br /> GIS Coordinates:X Y Townshlp Ran e <br /> 9 Suction <br /> WORK TO BE PERFORMED• <br /> [I NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER`) �UESTRUCTION <br /> E]SOIL BORING# (choose tya below) <br /> [)WELL# �4MV@R-BORE. DIAMETER 7 <br /> []'Other /9 rrW-SSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: M W <br /> ZYPE_. O� 1NSTALLAMN TYCE CONSTRUCTION SPEC FiCATiONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE I]MULTIPLE CASINGS R MULTI-LEVEL WELL CASING DIA Z <br /> D EXTRACTION Q AIR•HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 1. <br /> 0 VAPOR STEEL PVC p OTHER <br /> E1 MUD ROTARY DEPTH OF GROUT SI:gL PREMIE TYPE TO BE USED; II AUGERS 13 HOSE <br /> a AIR SPARGFJ OZONE U PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 11yea tl No (NOTE; MAXIMUM FREE-FALL DEPTH IS 30' <br /> U SOIL BORING 0 FANDAUGER GROUT-SPECIFICATIONS <br /> j' <br /> Q OTHER n OTHER APPROX.BORING OEPTK 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS: <br /> CONDUCTOR CASING PROP"ED.(if YES,hat speciflcetlons In comment section) <br /> - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Re ulations,and all applicable California State Laws. <br /> SignTltla/Company s+r• �^'�'���Irl•tt'.� Spec.'./.•J7' <br /> Print <br /> Signe x Name /"` 4-4.a•f A : 7,7rn r • Dete F /4 <br /> OF C 6 <br /> QEP 11;6.1 T USE ONLY <br /> SITE MAP IN UNIT IV FILE, D ESS: <br /> WORK PLAN DATED: 147 10 21Cir51 <br /> Application Accepted By Date Issued- W&I 10c, Arca 9 2 <br /> Groutlnapec0on By DataFtnallnspealon By Date / <br /> Destruction tnsptoction By Date <br /> ?170 b <br /> COMMEN'T'S)CONDITIONS; L61 - r- +Al 7 <br /> ACCOUNTING ONLY: AID# FACN <br /> PEC FLE INFO AMOUNT REMITTED CHECK E RECD BY bATE PERMIT 1 SERVICE REQUEST# INVOICE <br /> OF lljp� 3�ZD VuG SR# <br /> C-57— WC -WAIVER_-__ C-57 Letter of Authorization to sign permit_ Encroachment duct <br /> rM 29.02.001 <br /> 6/22/04 <br />