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10/06/2005 13 41 2094683433 EHD PAGE 02 <br /> San Joaquin County <br /> Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202 MITIGATION <br />,solo (209)468-3449 Fax (209)468-3433 'Web www sjgov.or&/ehd UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> APPlteaWn is hereby made to San Joaquin County tot a perrniit!o cornhwt and/or uistall the work 00SCAbed 'Etas applications tt%49 in cornp&ance vath San <br /> .Joaquin County DeYgopowtt}i7itie,Chapter 9-1115 3 and the Standards of San Joaquin County F,.rtlrtronmr�ial Health Departmant- y�r �f <br /> WELL Location ��1 1 'V .� ��Cross Stroet C[over C11Y.��� Trp rl��Paroelif�c�(����f I <br /> PROPERTY ` Opp D <br /> Ovm91 'rr �V� dross OrtY Zp U�It �h <br />' C-rr contracW dress o>< 3`3 cit r zrp luc� �� Plhone#_ 23, 'F�t3t� <br /> Consultant/Sub Cntr�„ �� Address 29 } �icLbr�JCM�s GryLx� Pnonelk�l6 �P r Z7�b <br /> GIS Coordinates N ,Y ,TownsHp R ...r...secbvi <br /> WORK To BE PERFORM <br /> 11 NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER OTHER-) ,8015STRUCTION (choose type be" <br /> 0 SOIL BORING# rE. DIAMETER,_ lQ <br /> rr <br /> 0 WELL N 0 PRESSURE GROUT <br /> a ftOthr GROUT SPECIFICATIONS <br /> COMMENTS S ✓� t'.r. 1r-�a.� %tet L.-.s3— <br /> T"E OF WELL LALLATION TYPE C—Q I—M fiUG QQN,SPECIFICATIQIJS <br /> MMONiTOftING li HOLLOW STEM DIA.OF 13OREHOW 13 MULTIPLE CASINGS <br /> JI MUL7t-LEVEL 1NELLCASING DLA. <br /> 11 EXTRACTION ©AIR HAMIMEWDRIVEN CASING THICKNESS TYPE OF CASING <br /> 11 STEEL 1]PVC U OTI-IEI2 <br />%EF <br /> POR II MUD ROTARY DEPTH OF GROW SEAL TREMIE TYPE TO UZ USED a AUGERS 0 HOSE <br /> SPARGE]OZONE 0 PUSH POINT(GP or CPTJGROUT SEAL PUMPED [1 Yes U No (NOTE: MAXIMUM FREE-FALL DEPTH 15 301) <br /> fi_BORING 0 HAND AUOM GROUT SPECIFICATIONS <br /> 0 OTHER„ � 0 OTHER APPROX BORING DEPTH p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> COMMENTS CONDUCTOR CASING PROPOSED Rra <br /> (d YES,Inst spedbons In continent section) <br />' NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOT1C9 REQUIRED FOR INSPECTIONS. <br /> I hereby certify that I have prepared tt>sis application and that the work will be done in accordance with San Joaquin i <br /> County Ordinan RU Regulations,and all applicable California State Laws. Fol` —it'5{�— <br /> S,gned TaleJcompany G(� <br /> Pnrn Name 1 Date b <br /> DEPARTMENT USE ONLY <br /> SITE NAP IN UNIT IV FILE D SS: <br />' WORK PLAN DATED: Z�G Zoo <br /> AppkadoitAxePted Oy _.0k � a Issued 10 e7� lead <br /> Grout Inspection By— Date Final lnspeaon By _-- <br /> De"VGtron Inspection By Date <br /> M MENTS/CONDITIONS <br /> ACCOUNTING ONLY AIDC! FAC* <br /> PE CODES FEE INFO AMOUNT REJ41MM CHECK 9 it;ECBY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ror� a SR#V15 DL7.17 <br /> C-57 WCC WArvER-- C-57 Letter of Authorization to sign pertnit Encroachment doc <br /> END 29-02-001 <br />