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10/20/2004 16: 25 9166385611 CASCADEDRILLING PAGE 83/06 <br /> 10!20/2004 1-427 FAX 9166792000 <br /> "1ET- D San Joaquin County <br /> vilronmental Health Aepa>rtmen't SITE <br /> u }East Weber Avenue,3rd Floor,Stockton,CA 95202 mi�I�AT�OM <br /> • (309)468-3449 Fax:(209)46&3433 Web:www,sjgov.org/ehd UNIT IV <br /> { 10NMPNT HEALTH Well Permit Application <br /> PPRMITISERVN�ES.RVFUNl7A$Lt~PERMIT EXPIRES 1 YEAR FROM DAT!~19sUlwD <br /> Appllcatlon Is hereby made to San Joaquin County for to parmll to construct andlor lnstall th0 work deaerined. 'This appllrallon is made In cvrtpttal�wlttt San <br /> Joaquin County Development Title,Chaptar 9-1115.3 and the 5tandards of San Joaquin County t;nvlronnmwer al k'teftlttl DapartmenL <br /> Assessors <br /> WELL Locatlon 1 bili ) 1Fwt�w� C L Cross Street%5-tytwoceIcay S R <br /> PeICelR <br /> PROPER LY , O Address �D 4 � Z L� -�-Cxy ra p 4 �O Phone# S_Z _W 9 1 <br /> Owner • V Qa V.C;' <br /> C-t37ContraMor Cu pv Address 3103 GCity �br � lP �n �f f4' � <br /> Consultant I Sub Cntr_ �y�(' ring rM rL a0.6 .IVC u�y City 5aG Nle -Phont:51! `Zt7 SL/ <br /> GIS❑oordinales:X ,Y ,Townallip Range Section <br /> ARW <br /> WEL�LMEBORING (CPT,GEOPROBE,WDROPUNCH,HAND-AUGIEk.OTHERhDOES RUCTION {choose type tse[ovry <br /> BORING# a OV -DORE. DIAMETER - - <br /> []PRESSURE GROUT <br /> , L t GR SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF ME IN CAItLAT14.N_TY!'E CON N 8PECjI3q&Tj= I /J <br /> -"OMTORING )R:Z!OLLOW STEM DIA.OF B05iSHOLEg?_!�Z-0 MULTI PLS CASINGS 0 MVLTI-LEVEL WELL CASING DIA _ <br /> I]IrJCTFiACTI ON Q AIR HAMMEt41DRlVt;N CASING-MICKNESS SC 1ti_I TYPI=OF CASING: p STEEL )8tVC 0 OTHER: <br /> p vAPOR p 11UD ROTARY DEPTH OF GROUT SEAL_ - 7RE111E TYPE TO BE USED: �UGERS Q HOSE <br /> p AIR SPARGFJ OZONS p PUSH Po[NT(GP ur CPT)GROU'f SEAL PUMPED:�Y.ea U No (NOTE: MAXIMUM FREE-FALL DEPTH IS 36') <br /> 0 SOIL BODING {I HMO AUGER GROUT SPF.CIF[CATION9 <br /> 0 OTHER: fl OTHER APPROX.sORING DEPTH�IS t A. SOI JLTED TRAFFIC BOX or 0 STOVE PIPE <br /> C NDUCTOR C SING PROPOSED (if YES,fist spedAcations in comment section) <br /> COMMENTS, <br /> NOTE: OFFSITh BORINGS RI=QUIRE ACCESS AGREEMENT OR FENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have repared this plical:lon and that the work will be done In accordaanen with San Joaquin <br /> County Ordin ces,R le nd ula s,and all applicable Califomis State LRwS. <br /> 8lgned IrTIt1alCartrpan (i17. T�+G d/ Lf/G <br /> Print Name 4 Date <br /> gRPARTMENT USE ONLY <br /> SITE MAA IN UNIT IV FILE,ADDRESS' 16, 12— i- -d ky_e t'r�("—e-- <br /> WORK PLAN DATED:,, <br /> AppliicationAccopted t3y Date[ssoed Area ^ <br /> C,rW Inspection BY Dale Final inspenllon By Date <br /> Destruction inspection By ,�� _..,.,..,_......,..._.....�... <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY: AID# FACS[ <br /> PE COIR 8 fEE INFO AMOUNT1REMITTeo CHECK# RECID BY DATE PERMI!'I Sr=WCE REQUEST# INVOICE <br /> SR# C> 6 <br /> C-57� WC-WAIVER C-57 Letter of Authorization to sign permit Encroachment dor-_ <br /> ZND 29-02.001 <br /> ��2zma <br /> i� <br />