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Apr 28 05 11 : 30a3 <br /> P. <br /> 0 0. I co San Joaquin County <br /> p a Environmental Health Department SITE <br /> 304 East Weber Avenue,3rd Floor,Stockton, CA 95202 MITIGATION <br /> (209)468-3449 Fax: (209)465-3433 We :www,sigov.org/ehd <br /> �qt•: .��a bUNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permil to construct and/or Install the work described. This application is made in compliance with San <br /> Joaquin County Delvellop(m''enntt.Title, <br /> ,C(haa'pter 9-11x115.3 and the Standards of San <br /> �(Joaquin County Environmental Health Department <br /> , fin! r) ,/(ILS,^ ) <br /> WELL Location"'Z c7 co ✓ aq &I Cross Street V / 33 y Zip �S3�✓Parcel#N L"/W NO"�..J <br /> r Cit <br /> PROPER {� �.12d�a/+, S �([ <br /> Owner }J/. G ��n�/V Atldress btZ/.�Q IA/ ()�� �P City_ ,� ZIP- L�PhoneQ#F / c -Q 9f' ---Peg <br /> C-57 Contractor�� -r(,-b,l I((&f(rAddress �/�� ,t7CJh!(; City�IP U OJ 14 / n(. 007 <br /> Consultant/Sub Cntr J0 <br /> �1(C II oAddresso0 pvn) r R-I•q CityWAQfe# 6* Phone#7�6- 9g1- <br /> GIS Coordinates:X 3 ,�y I,/,�I �(,1 II •Township­ Range C—GL� <br /> _ Section <br /> WORK TO BE PERFORMED: <br /> NEW tAWELL I BORING PT, EOP O E YDROPUNCH,}1AN0-AUGER,OTHER') U DESTRUCTION (choose type below) <br /> ❑WEILL#ORiNG# J S'8�i�/��' <br /> II OVER-BORE. DIAMETER <br /> a"Other 0 PRESSURE GROUT <br /> COMMENTS:_l✓ <br /> ��p/��Cl7�Fi �)h'P GROUT SPECIFICATIONS <br /> `J"(� <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING HOLLOW STEM DIA.OFDIA.OF BOREHO�t� Q MULT# <br /> t� IPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> p EXTRACTION a AIR HAMMERIDRIVEN CASING THICKNESS /Vfil- TYPE OF CASING: p STEEL 0 PVC Q OTHER: <br /> 11 VAPOR a MUD ROTARY DEPTH OF GROUT SEAL O—7-D TRE <br /> MIE TYPE TO BE USED: &UGERS fI05E <br /> a AIR SPARGE/OZONEPUSH POINT(GP orCPT)GROUT SEAL PUMPED: Ves p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> Al" <br /> SOIL BORING -INAND AUGER GROUT SPECIFICATIONS 'Au <br /> 1 r��t7tn" <br /> OTHER: p OTHER APPROX.BORING DEPTH_ `tU F E. d BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> /CONDUCTOR CA-SCIN�jGP,R(O,,POSED (if YES,list specit'ications in comment section) <br /> COMMENTS: i�"I�f/V4 7 �V(K �pc Cr;G'G�yI7 X-E//�1 SG?2-> - %ZFIr --. AEI_ <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 prepa this application and t the ark Will be done in accordance With San J a U' �y / <br /> County Ordinan es, R I and _Tu ulations,ar I Ile, �i State � 9 <br /> (/� <br /> Signed x / 'I Gtr Ti11 S/_Company_Z� OIL�N ST <br /> Print Name L C Date a— <br /> �i/i �cd;ZEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Grout Inspection By Area <br /> Date Final Inspection By <br /> Date <br /> Destruction Inspection By Dale <br /> COMMENTS/CONDITIONS: <br /> ACCOUNT"ING ONLY: AID# <br /> TBFAC#PECODES FEEINFO AMOUNTREMITTED CHECK# Y DATE PERMIT I SERVICE REQUEST# INVOICE <br /> _ SR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc <br /> EHD 29-02-001 <br /> 6/22/04 <br />