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10/06/2005 13 41 2094683433 EHD PAGE e5 <br /> ♦ e <br /> V 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 IV <br /> Cp <br /> Wel! Permit Application - <br /> N0N4:tEMNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Appkaaon is hwoby made to San.IoaWn County for a permit to combimt andlor=tau the work descn-bed This application is made in comprorwe worn San <br /> Joaquin County Development Title,ChapW 9-1[175.93 and the Standards of San Joaquin County Envtronnrerrial Health Depaartroorrrt <br /> Asiiessars <br /> WELL Location Z G O M'�C1 rocs Street r&a City Zip_ 7 �Par�1# f_�p j 5 <br /> PROPoww eTY ,1 +45G A Phoned` <br /> Owner Address � W* � <br /> car Contractor 't r address caty U a Zip I. 5516 jP`nor <br /> GORsuttant J Sub Critr l)'P. ____AddressPr�onerAk6 61 <br /> GIS Coordinates X Y Township Range Sr-it <br /> WORK TO BE PERFORMED. <br /> p NEW WELL/BORING (CPT.GEOPROBB,HYUROPUt4CH,RAM-AUGER,oTHM':V) >6ESTRUCTiON (d,onse ape belo►y) <br /> B SOIL BORING*_ R BORE. t�1a1M t7 �` <br /> Il VVEI-L$ 0 PRESSURE GROUT <br /> C*Mar GROUT CIFICATIONS <br /> COMMENTS <br /> TYt OF ML 1MAL LA'# 1!TYPE CONSTRUgT 35PIECLFiCATi0u1S <br /> bWONrrORiNG 11 HOLLOW STEM DLA.OF BOREHOLE 1]MULTIPLE CASINGS 0 MULTI-LEVEL WELL.CASING Dtk <br /> 0 EXTRACTION 0 AIR HAMMERIVR1VEN CASING TFUCKNESS TYPE OF CASING 0 STM 0 PVC 0 OTFIER <br /> VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED' []AUGERS Q HOSE <br /> AIR SPARGEI OZONE a PUSH FONT(GP or CPT)GROU T SEAL PUMPED 0 Yes 1]No (NOTE- MAXIMUM FREE-FALL DEPTH 15 30) <br /> 0 SOIL DORING 0 HAND AUGER GROUT SPECIFICATIONS <br /> 12 OTHER _ _ 6 OTHER APPROX BORING DEPTH a BOLTED TRAFFIC BOX or p STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list speaicaflons rn Comment Section) <br /> COMMI=Tors• <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 40 WORT KING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> hereby certify that i have prepared this application and that the work will be done In accurciance with San Joaquin <br /> County Or'dinanc R and egulations,and all applicable California State LarwS.� 36t . ' b� ' ,�— �� <br /> SVned x Ti9elCornpany 17!� <br /> t pant Name r� Uata y <br /> DEPARTMENT USE ONLY <br />' SITE MAP IN UNIT N FILE, DRESS: <br /> WORK PLAN DATED. 2-�'2—�0Q <br /> Application Aooepted BY W ., .—�., Date Issued odd o y .. <br /> Grout Inspectlon By Date Final Inspection By- t Dat_ <br /> C mbixtion Impec*on By Date <br /> COMMENTS T CONDITIONS., -- <br /> UPECMODES <br /> G ONLY AII� FAC# <br /> FEE INFO AIMIOUNT R�fA14 1 CHI=CK 4 ITEC"D BY DAT�E PERMIT!SERVICE REQUEST# INV(XCE <br /> SFZ# <br /> C-57 WC---WAVER— C-57 Letter of Authorization to Sign permit Encroachment doc_ <br /> 6i=04+02-001 <br />