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12/09/2004 15:11 464013E i ENVIRONMENTAL HE, j" PAGE 01 <br /> San Joaquin County w+ <br /> 4 ' Fnvironmentat Health Department SITE <br /> 304 East Weber Avenue,3id Floor,Stockton,CA 95202 MITIGATION <br /> (209)465-3449 Fax: (209)468w <br /> 3433 Web: vm .sjgoY.org/ehd UNIT IV <br /> Well Permit`pplication <br /> NON-REPUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appll=flon Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made In compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 andSStt dards'io San J aquin County Environmental alth epartment. <br /> Asseors '30 <br /> WELL Location /fit. Cross Slreet `"'� 4' Clty � 5.�� Parcel#ss (' <br /> PROPERTY y(✓ � w /�' ' / (-Z( <br /> Owner �s?� I the !1 City A(J�L" � <br /> c-67CantractarFISWl' FpwyOnil+ c LeasSYe" AeArs Y ciy <br /> Cohadltantl Sub Cnt J Vl A01�✓l�Address - ,� L� n CIt Phonc# 2iGa I"3-6%L 8' <br /> / •� <br /> GIS Ceortllnates:X -e-v',79-7 .Y �� +nahp Rause ) section I <br /> ORP BE PERFORMED• <br /> NEW WELL I BORINGj T OPRO ,HYDROPUNCH,HAND-AUGER,OTHER") 0 DESTRUCTION (chcowtype below) <br /> �- 01L BORING# S �I a OVER-RORE. DIAMETER <br /> WELL# II! 0 PRESSURE GROUT <br /> 0"Other ;F _ GROUT SPECIFICATIONS <br /> COMMENTS: <br /> II O <br /> TYPE OF WELL INSTALLATION TYPE C STRUCTION 3 EdPICA710N <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS B MULTI-LFVEL WELL CASING DIA: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL 0 PVC BOTHER: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE \) <br /> `n AIR SPARnE OZONE PUSH POINT(GP or CPT) SEAL PUMPED: Q Yes p No.(NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> g501L BORING 0 HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC BOX or p STOVE PIPE <br /> D OTHER: O OTHER _ APPROX.BORING DEPTH D , <br /> CONDUCTORtICASING PROPOSED _(if YES,list specifications in comment section) <br /> COMMENTS: II - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCT ESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 411 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify th I have prepared this application and that the work will be done In accordance with San Joaquin <br /> Coun i D s, las n gu e ' ,and all applicable California State Laws. <br /> $ignedx �' TldelCOmpany <br /> Lt A e 1 <br /> ` 4-—_4 U <br /> Print Name lL'.Ye <br /> EPARTMENT USE ONLY ' <br /> `� <br /> SITE MAF IN UNIT IV.FILE ADD IE / 1 <br /> WORK PLAN DATED:_ c) I• a a <br /> y Date Issued �1 Aree <br /> Application Accepted By Date / ZO 0 Final Iwpedlon By Date <br /> Grout Inspection By_, - � Date 11 <br /> Dastmaon Inspemion I <br /> 1 <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID>x r <br /> I FAC# <br /> PECODES FEEINEO AMOUNT REMITTED GHECKN REC'DBY DATE PERMITlsBRVICE REOUESTB INVOICE <br /> a�50 8 <br /> C 57, WCC WAIVER, C-57 Letter of Allithorization to Sign permit,Encroachment riot_ <br /> E14D 29"o3-eel <br /> 6,22/04 <br /> { <br /> i <br /> �I <br /> lj <br />