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10/06/2005 13 41 2094683433 EHD PAGE 04 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Fjoor, Stockton,CA 95202 MITIGATION <br /> • (209)4683449 Fax (209)468-3433 Web:www.sigov orWehd UNIT IV <br /> 4 Well Permit Application <br /> W NatEFVgt)AsLE PERMIT EXPIRES 1 YEAR FROM bATE ISSUED <br /> Appgcation is hereby made to San Joaquin County for a penin to Construct andror instal the work described This appkmteon is made in eanpfiance with San <br /> Joaquin County Development Title,Opfer 91145 3 arKVIhe Standards of San Joaquin Courdy Environmental Health Department <br /> r FISSeSbOra <br /> VMLL L*=Uon.34�x $1 vd cross Street CZoVQr R a coy �3"�-��aroew 1 it$.p?A <br /> PROPERTY <br /> Owner C.� Address City 7jp Phone* <br /> G57 contractor oa 'brz r ddn3ss 33<r City X10 f Tp K r L W L,6Xi Mwrrr:# 3 �_`!3�❑ <br /> Consultants Sub A4dmny-yYo i-4w mks -c+h�.l phor,aa �il�G-r f- zC <br /> ..... _ zt- ..9do 4 <br /> GAS Coordinates X 'y Township Rarve Sech <br /> W RK TO BE PRFORMED. <br /> p NEW WELL l BORING (CPT.GEOPROBE,HYMOPUNCH,HAND-AVORR,OTHER") tOESTRUCTION (dx*$e type b81 <br /> 11 SOIL 5M11G# �9VER-BORE DIAMETER /D" !2`r <br /> Q WELL A 1]PRESSURE GROUT <br /> 11.Other GROUT SPECIFICATION$ <br /> COMMENTS 1 O �`, . ... —�oci ops ,,.aLa:.' - <br /> TYPE OF WELL INSTAXI ATION TYKE CO sTpucT10 PECIFICATI NS <br /> it <br /> NITORING AfLIOLLOW STEM DIA.OF BOREHOLE-, ©MLrLTIPLE WISINGS U MULTI-LEVEL WS-L CASING DLA. Z �f <br /> 13 EKTRACTION 0 AIR 1•IAMMMORIVEN CASING THICKNESS_ _ ,r TYPE OF CASING g STEEL Vvw U OTHER <br /> VAi'OFt 13 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED ],)AUGERS 1]HOSE <br /> R SPARGEJ OZONE I]PUSH POINT(GP or CPT)GR0UT SEAL PUF4KD eEr-(as a No (NOTE: MAXIMUM FREE•FALL DEPTH IS 301) <br /> SAIL SORING II HAND AUGER GROUT SPECIFICAMONS <br />' ©OTHER I4 OTHER`, „- _ APPROX BORING DEPS 3 � r1 h LTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YkS,IIsi In Comment section) <br /> CORAMEN75. q 1 'L �7�1�5 2��� 5-" 'r �c11 2-4 <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and R ulaftris, and all applicable California State Laws. <br /> Signed Titlelcompany t'Q S <br /> Print Name 'r✓Ka.l- Date S 3o ao* <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD SS: - <br /> WORK PLAN DATED: -c 2_04_7_0 6 <br /> ApprRmIlon Acoepted By X . pate IsqueU ��'7 ��S Ar6a — <br /> Grout Inspection By Date f=inal Inspection By Date <br /> DeStnx*0n lnSPecfon By Date <br /> COMMENTS I GONDLT o"s <br /> ACCOUNTING ONLY AM* Fpm <br /> PE COOLS FEE INFO AMOUNT REMTT FD CHECK# REC'D BY DATE PERMIT/SEMCP-REQUEST# INVOICE <br /> sr57 WC •WA�vEI�._ C-57 !.e#ter df AUthor•Izoltratl to sign pwmrt Encrouchment doe <br /> �� <br /> Qoi <br />