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10/06/2005 13 41 2094683433 EHD PAGE 03 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue, 3rd door,Stockton, CA 95202 MITIGATION <br /> *Imp <br /> (209)468-3449 Fax.(209)468-3433 Web www.sjgov.org/ehd IT III <br /> Well Permit Application <br /> NON-REFUNCABLE PEMIT EXPIRES I YEAR FROM DAT»14SWED <br /> Application is hereby made to San Joaqum County for a perriitj to c;ori„truct an0lor install the work descrbed This applicaborl Is made in Compii3nee w th Sall <br /> Joaquin County l7aMopmenl T-Me.Chapter 9-111116.3 and the Standards of lSan Joaquin Cou*Enviroi-,mrital Health Deparartert <br /> WELL Locabca_ � p �i1+J Cross$treat C l Q11�11 Clly zip <br /> PROP TY <br /> Owner 9 -AddressPtwil�e>t7i1 2� <br /> Cyr CiorMraclor I- Addr833`tLJ I7F3X Ci S `kl'auca'l00'9 <br /> ConsultamISub Or& V S Address-L-%-q0 <br /> GIS Coordinates X _ Y ... Township Range Sectivri <br /> MRK 12 RE PERFORMED• <br /> d NEW WELL!BORING (CPT,GEOPROSE.HYDROPUNCH,BAND AUGER.OTHER"') PIFOSSTRUCTION (diose type bdoy) <br /> n SOIL BORINGS — i AVER-8086 OIANIFTER Z-n r <br /> 131NELL#-_ 0 PRESSURE GROUT <br /> n*Other GROUT SPECIFI ONS <br /> cOM�at NTs <br /> its h C, e. a` A fQ q,13 <br /> , z <br /> TYPE OF WELL. gYSTALL&TION TYPE NPC-CIRCAI'IONS <br /> D$`FAOMTORING n HOLLOW STEM DIA.OF BOREHOLE D MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA, <br /> 13 EXTRACTION n AIR HAMMERIDMVEN CASING THICKNESS TYPE OF CASING n STEa n PVC n OTHER <br /> VAPOR o MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED n AUGERS n HOSE <br /> AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED n Yes 0 No (NO'T'E;MAXIMUM FREE-FALL DEPTH IS 30") <br /> 0 SOIL BORING 13 HAND AVGER GROUT SPECIFICATIONS <br /> ©OTHER h QTHER APPROK WRING DEPTH n BOLTED TRAFFIC:BOX or n STOVE PIPE <br /> CONDUCTOR CASING PIROPQ5EU (if YES.fist specifitaftu ul 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 thlx application and that the work will be done in accordance with Sn aguln <br /> County ordinean les nd R tions,and all applicable California State Laws/.&t, s v" <br /> Signed x TittelGOrsipar v l f S <br /> Pard IVsrne DateZ.� o <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV RILE,ADDRESS: <br /> WORK PLAN DATED: 268 <br /> Apocatron Accepted lay .. _._— _ Date Issued r6_ 1 G'„ _ ,e,i�a `� / '7 <br /> Grout btSpeCt n ey— _ Date Final Inspecaw By Dale <br /> D bucbm ft spechon By Date <br /> C01MMENTS 1 CONDITIONS <br /> ACCOUI+MNG ONLY AID* FAC* <br /> PE LOOM FEE ENFO AMOUW REM1TM D CHECK# RECD BY DATE PERWr1 SE9=E REQUEST# INVOICE <br /> 3 two` 60' ave G -�- la Q� �a"2.3 <br /> C-57 WC -WAVIER_,.._ C-57 Letter of Authorization to sign perWt Emcroach111erit doc�.— <br />' E1m zy-oz ao1 <br /> 6rzzroa <br />