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PROPE <br />Owner <br />C.S7 Contraoto <br /> <br />NLV.V I o-1,-.1L-. U <br />MRY -26-2005 15;37 <br /> <br />P.2/3 <br />San Joaquin County <br />Environmental Health Department <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3449 Fax (209) 468-3433 Web: www.sjgov,orgichd <br />Well Permit Application <br />NON.REPUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />AppilostIon la hereby mode lo San Joaquin County for a permit to dontdruct and/or install the work described. This applIcallon is made in compliance wIth San <br />AddreaalletiMAS4a Citygbabn Lica PhopettElliaa -0§5 <br />GIS Coordinates: X , Y <br /> <br />, Townahlp <br /> <br />Range Section <br /> <br />WORK TO Bg PERFORmEA <br />NEW WELL! BORING CPT, GF_OPROBE, HYDROPIJNON. HAND-AUGER. OTHER') <br />a SOIL BORING g <br />J WELL* a 'Other <br />COMMENTS: <br />YSESTRUCTION (chomp type below) <br />'fl I:IRBORE. DIAMETER <br />RESSURE GROUT <br />GROUT SPECIFICATIONS I <br /> <br />TYPE OF WELL INVALLATIoN TYPE DONBTRIXTION SPMFICATIONS <br />700NiTORING 0 HOLLOW STEM DIA, OF BOREHOLE. _ a MULTIPLE CASINSS (J MULTI-LEVEL WELL. CASING DIA: <br />I] EXTRACTION a AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: a STEEL a PVC a OTHER: <br />a vApoR a MUD ROTARY DEPTH OF GROUT SEA TREMIE TYPE TO BE USED: 13 AUGERS a HOSE <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT)GROUT SEAL PUMPED: El Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301 ) <br />a SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br />u OTHER: D OTHER APPROX. BORING DEPTH . 0 BOLTED TRAFFIC BOX or r] STOVE PIPE <br />CONDUCTOR CASING PROPOSED (ff YES, list speOficatIons In comment section) <br />COMMENTS. <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 prepared this application and that the work will be done in accordance with San Joaquin <br />County Ordi es <br />Signed <br /> and ulatIone, and all applicable California State Laws. A s Trfle/GompanyCeliar 6-4ce.a.0 , . <br />PrInt Name Dote ..E.17.46 <br />DEPARTMENT USE ONLY <br />WORK PLAN DATED: 4/ 2-4, 1005 (6-14"-A-4-,t4A-, <br />Date is.sued 6 ///b <br />Date <br /> Area -7 <br />-#7 1q <br />ACCOUNTING ONLY <br />.. <br />AIDE <br />. __. ..—____ <br />FACA _ <br />...._. ..... . — _ <br />p PE CODES FEE INFO AMOUNT REMITTED <br />_ <br />CHECK ft REC'D BY DATE .g., A REQU a INVOICE <br />37S-oz, 60- SR# <br />C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachmant doc <br />END 29-02-001 <br />6r22/04 <br />SITE <br />MITIGATION <br />UNIT IV <br />Joaquin County Development Chapter 0-1115,3 end the Standards of San Joaquin County Environmental Health Depanrnent. <br />ASsessors <br />WELL Location 45 <br /> <br /> efet 4°51 rT I f /7 Cross Stvect aiery City MVPO___ZIP pircep 005-1 - 2-b <br />AddressCV fatioiph City Kap& ZJSZhonsul <br />eldress Ca Ld CM/ Radirrt-zieW3Uc#infiePh*neat <br />Consultant / Sub Ont. <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />ApplioatIon Accepted By <br />Grout Inspection By DatO <br />Destruction Inspection a ak'et..--nre--41--- Date <br />COMMENTS r CONomONS. <br />Final Inspection By <br />0