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12/eS/2005 1S 24 2094683433 EHD Pam 02 <br /> WELL PERMIT APPLICATION` m" T� <br /> SAN JOAQUIN COUNTY � `- <br /> MENVIRONMENTAL HEALTH DEPARTMENT ITIGAT#�N <br /> 304 E. Weber, Third Floor, Stockton, CA., 9%T 4 2005 UNIT IV <br /> 1P (209) 468-3449 EWRCINMENT HFAM- <br /> NON-REQ.)NDARLE PERMIT t=XPIRES 1EARAR FROM DATCWSEFMCES <br /> Appboation is hereby made to San,Iosc=CoLtnty for a pemut to construct andlor Install the work described into apl =etron is made in compliance with San <br /> JMgwll COtrn*y Development Title„Chapter 5-1115 3 and the St uxJards of San Joaquin County Env,ronmen#at Heath Department. <br /> Assessors <br /> WELL Locahon9 0 r2/ p 16 p Cross shw - Cary Tip arceJ <br /> PCRwner `S Cleo >�1`:t WO <br /> Adi4r2s5^�Jl W_�[.JE1 ,�1Yn+n 1`[Ja^C�ty z,-U,61,61 Phone#„ <br /> C-57 Contractor Q If, to Address& 9 U6x f9 ( nC �o�ty �l Tap 57 -7 _Phone#- -71 V-4 <br /> Consultant/Sub Cntr5 u 7'Acldr- a�41 4 A, 4lM =-P4f Powe# <br /> GIS Coordinates x ,Y_ Township Range Section- - <br /> YV >RK TO RE PERFORMED: <br /> NEW WELL I BORING (CPT.GEOPROBE,HYDROPUNCH.HAND-AUGER,OTHER`) ll DESTRUCTION (choose type below) <br /> Q SOIL BORING 0 f�i/�rg) jjj �jl 11 OVER-BOFM <br /> DIAMETER _ f <br /> (I WELL# []PRESSURE GROUT <br /> 13*Other GROUT <br /> SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTAL&ATION TYPE CON5TRUCTI0N SPECIFICATIONS c1 <br /> f <br /> ONITORJNG }-HOLLOW STEM DIA.OF BOREHOLE) _ Q MULTIPLE CASINGS [j MULTI-LEVEL WELL CASING DLA '7' <br /> RCTION D AIR HAMMEWDR)VEN CASING THCKNESS { �TYPE OF CASING P STEEL VC j]OTHER _ <br /> [i MUD ROTARY DEPTH OF GPOUT SE4L YTREMIE TYPE TO BE USED El AUGERS n HOSE <br /> ©AIR SPARGE/OZONE a PUSH POWT(GP or CPT)GROUT SEAL.Pumrw 0 esI3 No (N TE,, MAXIM`U�S/M� FfR E-F LL DEPTH 13 30') <br /> [I SOIL BORING 1]WAND AUGER GROUT SPECIFICATIONS C�4uva ?,'f dj_btll lfro�t?T % 40AA, <br /> 0 OTHER_ _ rT OTHER= APPROX BORING QEPnq a BOLTED TRAFFIC BOX or n STOVE PIPE <br /> CONDUCTOR CASING PROPOSED - ^0 - (,f YES,fest speclflcaftons In oornment secton) <br /> COMMS TS <br /> NOTE: OFFSITE BORINGS REQUIRE ,ACCESS AGREEMENT OR ENCROACHMENT PERMITS, <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable Californsa State Laws. <br /> signed Lr TrticlCompany UJ" 9�l•-AV Ale, `�';Ej . <br /> FnntName='�t►iIC/� gtc.l4d.71.uf�if2.p _ Date Gl R <br /> -' <br /> DEPARTMENT USE ONLY � <br /> 31'IE MAP IN UNIT IV FILE,ADDRESS:. .� S. � s6,n_ E.c.ss <br /> NORK PLAN DATED: <br /> ,pplicabon AGoepted By / <br /> Date IsstsBC O$ ee S Area � 3 <br /> 3Cout Inspection Sy Date Final Inspection 6y <br /> Qate <br /> astruchon Inspocbon Sy pate <br /> OMMEWrS 1 CONDITIONS �1 <br /> 74WM!NG ONLY AID: FAC#FZE INFp AM OVNT PANIfTTEt� CLi1zCf4# REC'D 8Y DATE I�>=RIVtI'C 1 SEIRViCE iRfi�U]_ST# CE <br /> 1 <br /> 44� 1?9 9I crIr Al ar <br />