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0 <br /> San Joaquin County GEC --1.� u <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95203''j — 1 2005 MITIGATION <br /> (209)468-3449 Fax: (209)468-3433 Web: www.sjgov.or��//ebd <br /> .p ENVV I FIi F,Lf; UNIT IV <br /> Well Permit Application PER' <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application 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 Titte,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department SNAW6'Ao&*'( <br /> WELL Location ;?1f49 ROTN READ Cross Street 10 C• LF�Tff�� C7 Assessors <br /> Na e�aAt City Zip /J�311 Parcel ors <br /> PROPER <br /> Owner TMDEFEi�S�GOGttliCS Address 8s0 AD IN city LA AP zp 330Phone#_:..., ' gOft6dey <br /> C57 Contractor Cf 5 &C bg&406- AddressJb3� CNi�' GZccE city N oa zip 915W&#717 10 Pha„e# -y/&9 <br /> Consultant I Sub Cntr UQS CORP. Address 197o BAIEr+IAy aordclty r4w"laff Phone# <br /> GIS Coordinates:X .Y ,Township Range ` Section <br /> WORK TO BE PERFORMED: <br /> Mw -1S(-A/ � r Akwq +7A M-' Sly A <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) DESTRUCTION (choose type below) 3 l TELLS <br /> u SOIL BORING# 0 VER-BORE. DIAMETER <br /> n WELL# RESSURE GROUT nn_ <br /> `Other GROUT SPECIFICATION$K�'�m'f�✓p <br /> COMMENTS: SVC Ar WWyk:A 517,r-66C41W J MA? A,L,� W&L r/°55Cµ'ICa7xJ f <br /> ), 3q° � <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ��{{ <br /> (..MONITORING a HOLLOW STEM DIA.OF BOREHOL a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA: T' <br /> n EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS SC�f 0 ' 0 TYPE OF CASING: Il STEELVC a OTHER: <br /> Q VAPOR EA <br /> MUD ROTARY DEPTH OF GROUT SL TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> a AIR SPARGFJ OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING II HAND AUGER GROUT SPECIFICATIONS <br /> u OTHER: H OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS <br /> 48 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 /> County Ordin nces, Rules and Regulations, and all applicable California <br /> /State <br /> eLLaws. <br /> Signed nn,,.. �/ /[�_ Title/Company /"KtNccT /3),gNAI'� �(/ ro <br /> Print Name gICF/fjir/> IlA-n/ /)Y,c�E' Dale <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> �// <br /> Application Accepted By rp+'IC..-e-f� Dale Issued /t/7(0 Area_TIL__ <br /> Grout Inspection By Date/,? 9 Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: NL[J J 62C IT to, L Ck -V— <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> aqo 60°g 66j /l -70,- SR#Ob Yq71 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ <br /> }THD 29-02-001 <br /> 6/22/04 <br />