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04/10/2002 15: 36 20S 033 FIFTH FLOOR,, PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DkU ISSUED <br /> Appllcatlon Is hereby made to San 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,Chater 9-1115$and the Standards of San Joaquin County Environmental Health DepartrnenL <br /> 4-1v,.:4a do.+3+.. Hwy VLo Q� Acr�ort Way ,Ap"x IS .,Lk�. % N a-wScc ,assessor's <br /> WELLLoeatlon c- u\ ,_D dvw\or Sknl;...Gross Street ClryZip Parcel# 25-7- D3-21 <br /> z Zg I� it e((o "LHSS yatldre55 3'15 N W:9 rJ: late Ciry W>1.vu..4' Cre�Zip 94598Phone# 9'r-S - 1-14- 4081 <br /> PROPERTY Owner Bt- tav\da <br /> C-57Contactor-Si tu.y,tiTAddreml-365 Wliw 465- ?-712- <br /> Consultant I Sub <br /> -112Consultant/Sub Contractor CN2cn K\LI_ Address \55 4"r--,& PHewclry � "IG3�� <br /> EXPT- <br /> 3131103 <br /> GIS Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: � / <br /> 0 NEW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER-) $'DESTRUCTION(choose type below) <br /> a SOIL BORING# \,f'6V ER-BORE <br /> 0 WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING U HOLLOW STEM DIA.OF BOREHOLE 9 " MULTIPLE CASINGS?0 YES YNO WELL CASING DIA: 2 <br /> a EXTRACTION - U AIR HAMMERIDRNEN CASING THICKNESS TYPE OF CASING O STEEL O PVC O OTHER: <br /> a VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 0 AUGERS 0 HOSE <br /> "R SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> ,OIL BORING aHAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER: n OTHER APPROX.BORING DEPTH p BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> -COMMENTS: ALn. WQ-1.)- CAkw�61`z�iov. r�ao-on a�v.S o..u.A. YQ,j � ' <br /> Q 0 - <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED 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 Ord'nances les and Regulations, and all applicable California State Laws. <br /> Signed x T,tle/Company t(LOS E CT E N G\N I- <br /> ?rimName ukp, S(1kb1N Date, OG46bCi1G 7.31 26Z2� <br /> DEPARTMENT USE ONLY n s <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: Q <br /> application Accepted By. L 2& Ct Date Issued <br /> 3rout Inspection y Date Final Inspection 8y 111 Date <br /> JestNCtion Im ction By Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> cerw <br /> .CODES FEEINFO AMOUNTREMITTED CHECKS REC'DBY DATE PERMIT SERVICE REQUEST# INVOICE <br /> 0 O- 3 „ 1N0t 02 sR# l ' <br /> C-57_ WC_WAIVER_ C-57 Letter of Autho Iz o sign permit_Encroachment doc 1/25/02 <br /> 1 <br />