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' 01/05/2005 10:05 20946834330 FIFTH FLOOR • PAGE 02 <br /> San Joaquin County <br /> r :c <br /> za Environmental Health Departmegt.„ <br /> woo 304 East Weber Avenue,3rd Floor,Stockton,CA 9520�;;'- ;i_+r `;L- k' MITIGATION <br /> (209)468.3449 Fax: (209)468-3433 Web:vAm-sjgov.org/elid <br /> Well Permit Application 04 DEC 29 AM 127 2!WNlT IV <br /> NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to Sen Joaquin County fora permit to construct and/or Install the work described. This application is made in Compliance with San <br /> Joaquin County Development Title,Chapter 9-111 ,3 a d the Standards of San Joaquin County Environmental Health Department. <br /> ' WELL Location,��ry 1 °I-�6%�jOu n I Assessors <br /> ��_Cron Street Y r City 'HY( lip 9 03 parcel# 1 6Z6—)3 <br /> PROPERTy-� (� ' a (t (�6W_61-II <br /> Owner fG' CT �'KC 46A dress_ZZJUI .i11eCNiM <br /> CSlrContractor l e/! Address —City—Zip LI 0/1; bPhone# <br /> Consulantf Sub Cntr }_aH .aSaS -crnaS <br /> Address i?,v4 -I]'Ja. G,'Fa25Cj(�yi pplBir qtp 1I1T' 1�1Phone# <br /> GIS Coordinates:X Y Township G9AC`l ., d Range (AW UIDAIQ Section <br /> ' :N20 TO BE PERFORMED: csyye.-F Heli;du j", <br /> 7NEW WELL/BORING <br /> 9SOIL BORINGCPT,GE PR BE,HPDR NCM,HAND-AUGER,OTHER-) F DESTRUCTION (chaose type below) <br /> J tE - �. <br /> DWELL# DOVER-BORE. DIAMETER <br /> ]]-Other 0 PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS r tij ' below d gkn a e__� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 11 MONITORING ]]HOLLDW STEM DIA OF SOREHoLE_.2L 0 MULTIPLE CASINGS ]]MULTI-LEVEL WELL CASING DIA: <br /> ]]EXTRACTION 11AIR HAMMERlDRIVEN CASING THICKNESS TYPE OF CASING: ]]STEEL ]]PVC POTHER: <br /> . O VAPOR 0MUD ROTARY DEPTH OF GROUT SEAL Ir-;, TREMIE TYPE TO BE USED; ]]AUGERS ]]HOSE <br /> ]]AIR SPARGE/OZONE "PUSH POINT(GP or C"GROUT SEAL PUMPEd: il Yes n No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> 014SORING 0HAND AUGER GROUT SPECIFICATIONS <br /> D OTHER: 0 OTHER APPROX.BORING DEPTH l5 ]]BOLTED TRAFFIC BOX or P STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (if YES.list specifications in Comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. P <br /> N <br /> I hereby certify that I have prepared this lication and that the work will be done in accordance with San Joaquin <br /> County Ordi nces, ul d Regul (ons and all applicable California S to Laws. <br /> Signedz i Tr9a/c mpany <br /> Print Name Y fff2 JJDaIe <br /> DEPARTMENT USE ONLY <br /> ISiTE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> tppiioation Accepted By_ � Date Issued I-z-( L?Sc <br /> Are, <br /> rout Inspacdan By. Date Final Inspection By pato <br /> Destruction Inspection By Date ll_' <br /> OMMENTS/CONDITIONS- 'T5 0.1.. <br /> ACCOUNTING ONLY: AID# FA <br /> PECODES FEEINFD AMOUNT REMITTED CHECK RECD BY I DATE PERMIT/SERVICE REQUEST# INVOICE <br /> Df ( $`i` �S�SZ [d(— / cf SR# dag3o <br /> C-57_ WG -WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc <br /> D 29.o2.001 <br /> voa <br />