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aria " � San Joaquin [:aunty CQP <br /> nv r®r>menta ealth Department <br /> Inc ?. y3.j 304 Fast Weber Avenue, 3rd Floor, Slockton, CA 95202 MITIGATION <br /> ,:�" (209) 468-3d49 Fax: (209)468-3433 Web: WwW-Sj90v.org/eh.d I`; :� UNIT IV <br /> Well Permit Application <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This apple-atlon is made in cornpllance wijh San <br /> Joaquin Co.Fnt [D etop ent Title, Chapter 9-1115-3 and the Standards of Sari Joaquin County Environmental Health Department. <br /> [�/}L! Assessors <br /> WELL Loca ion '1�c�S� k� v.r. Cross Sfreet A sc k €t �r� .v Zi 75 <br /> G�— Y_�__.—.� P__ _Parcel# - <br /> PROPERTY <br /> Owner-1`Jart y7la,n6� f Address o; �J.`��2wc rr GitY_.( --Eip `�s33t Phone# <br /> G-57 Contractor ` *� c' �ILfd#7a ,m Fhone# (7tL "777- Hf� <br /> - ?�- Address i3 o c �f �._ Ciiy�slc�, Zip �c L 9t ` <br /> Cons EJ€tantl Sub Cnlr_ G-CO fi E-.Cs p-e_C Address =1;'n �°u- ` _� tY_. ct�cLic# Phase �73_� i7(j/i3 <br /> G1S Coordinates:X Y ----_ ,Township__ ­Range "—_­_._Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL 1 130RiNG (CPT,GEOPROBF,HYDROPUNCH,HAND-AUGER,OTHER') 0 DESTRUCTION (choose type below) <br /> i]507[­BORING#_ _ 0 OVER-BORE. DIAMETER <br /> lNELL# �>N- -- <br /> --�.-----��.. a PRESSURE GROUT <br /> GROUT SPECIFICATIONS <br /> COMMENTS: - <br /> TYPE OF WELL €NSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 20ONITCRfNG HOLLOW STEM DIA. OF DQREHCLE d ' 0 MULTIPLE CASINGS []MULTI-LEVEL WELL.CASING DIA: <br /> j] EXTRACTION 0 AIR I-IAIJIMERlDRIVEN CASING THICKNESS',ct 1 G 9TYPE OF CASING: 0 STEEL ; 'PVC 0 OTHER:� — <br /> j]VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS 0 HOSE <br /> 0 AIR SPARGEI OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: 0 Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HANiDAUGER GROUT SPECIFICATIONS ile-<1 k- <br /> 0 OTHF_R:___ _ n OTHER___.-.V. APPROX. BORING DEPTH__ 0 BOLTED TRAFFIC€30X or `{STOVE PIPE <br /> CONDUCTOR CASING PROPOSED___ (if YES,list specifica€ions in cornrnent 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 Ordinances, Ru an Regulations, and all applicable California State Lavers. <br /> Signcd x_ TitIelCompany tA) (, q <br /> Print Name_ G CLC �rras��b Date RECEIVED <br /> _ % �l 0� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDR Ss: f� c�� 6� �E� 2 6 2005 <br /> WORK PLAN DATED: SAN JOAQUIN COUNTY <br /> AL <br /> Application Accepted ay .. Date Issued rjre$,a{EA TMEWNT <br /> Grout Inspecting t3y Dale" Final Inspection By- _ -___-Date <br /> Destruction Inspection By Date <br /> COMMENTS{CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> j PE CODES FEE INFO ` AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST A INVOICE <br /> C-57 WC -WAIVER C-57 Lefter of Authorization to sign permit Encroachment doc�^ <br /> 2131)?9-02-001 <br /> 6/22/011 <br />