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RUG 24 2004 5: 27PM LASERJET 3200 P 2 <br /> - --- •� �� nv uxuuN 513030; t4pyNo. <br /> 998 P02 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax:(209)468-3433 Web:www.sjgov.org/ehd UNIT N <br /> Well Permit Application WbV6 <br /> NON-REFUNDABLE PERMITEXPIRES 1 YEAR FROM DATE 155UED <br /> AppRCatlon le hair by rade Ao San Joaquin;ovnty for p pam*t0 con6rucf malar Ins'ail TB W"de4Crlhed. Thla aODYcaW tB made In ccmOlance with San <br /> Joaquin County Osvehpmer9 Ttlla,Cftapter 9-1116.3 and the StaNdsrds or San Joaquin County Emvlrorxnontel Haattt,Uopsltnant <br /> se <br /> y�!_ �f Asssum <br /> WELL Loeadan�t NT '���� . Groh&root ity �M1�tpip _a�rcelae��9'd5� -OSS <br /> Owmv 711 b r ry I 1 Addrsim 140 ZIPIOX—Phor*# d , <br /> CCCcntmetor�� --3)LL-L-4 AddPAIS City Alla/-Er }:C�f PfionwO J <br /> Consultant I Sub CnTO-AYIa a>� SfIG dsddMas 1qVj &kCltg� (r� Llc* Phonsa Z r - N <br /> GIB Coordinates;X ,Y TOfM6hlp b Range Section <br /> WORKTQEPER 211M <br /> p NEW WELL 113ORING (CPT,GEOPROBE,Hv IRCPUNCH,HANO-AUGER OTHER') ESTRUCT)ON (ch sa type balow) <br /> 0 SOIL BORING A / VVER-BORE, DIAMETER <br /> Q WELL y j,r�`�l0 WY Q PRESSURE GROUT <br /> *Other GROUT SP IF(CAT <br /> COMMENTS: D6 LA .0 LA- 1 r <br /> TYPE OF WELL INSTALLATION 31PE CONsTRUCTION SPECIFICATIONS <br /> 0 MONITORNG 0 HOLLOW STEAL 01A.OF BOREHOLEV 0 MULT)PLE CASINGS 0 MULTI-LEVEL WELL CASING OUi <br /> a EXTRACTION 1)AIR HAMMERJDRIVEN CASING THICKNESS TYPE OF CAbING; Q STEEL J PVC D OTHER <br /> Q VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TP TREM£TYPE TO BE USED: C AUGERSOSE <br /> Q A(R SPARGE/OZONE Q PUSH POINT(GP or:PT)GROUT SEAL PUMPED:- Q Yes Q No H 1 NOMAXI 1N�( M FREE-FALL DEPT30�) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS >� . z <br /> p OTHER: tl OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (I! YES,Pat rPOCAG M&In comment seeaon) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> "WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordl a sad lotions, and all epplleable California State Laws. <br /> SlgnaOR TkelCompanyL#'/ 1��"' <br /> plmtr Dato_ <br /> mt tN - <br /> DEPARTMENT USE ONLY <br /> SITE MAP M UMT IV FILE,ADDRESS: r r f <br /> - 7 <br /> ,e~�ril/EA �� <br /> WORK PLAN GATED: <br /> Daq l:�usd ���� A1se <br /> AppPaatlon AoteDtoO ey Oar 6 <br /> Grout IrrsPnotlon 8y Date Flnel InaPectlon t3y F y r <br /> 066MRAon Inepeoden BY Dets <br /> coMIMENTS I CONATIONS: <br /> ACCOUNTING ONLY: AIDS FACO <br /> PE cDoes FER INFO AMOUNT REMITTED CHECK A REC'b BY DATE PERMIT I SERVICE REQUEST r INVOICE <br /> Boz W 0- 3lo109 CV 8•z SRO 003f3� <br /> C-57_- WCC WAIVER_ C-57 Letter of Authorization to sign p�'mii Encroachment docs <br /> mm 29-M-M) <br /> 6x22/64 <br />