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04/10/2002 15:36 2094( *3 FIFTH FLOOR • PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) (�� <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 u u <br /> (209) 468-3449 AUG 2 7 2002 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DACE ISSUED <br /> Appllratlon Is hereby made tq San Joaquin County for a permit to constmat and/or install the work described. This epplica (NA Int} p r���f�San <br /> Joaquin County Developrnant Tifle,Cha t 9- 115.3 and the Standards of San oa uin CountyEnvironmental alth,De akpec T,�Ep� �EL <br /> p i 110 �>, A�f a(' Y �� q {1F /t? j mr�4 d- p rItri 9t4u / <br /> 4b ml)ts Sa�+l �U P ug , F x s <br /> WELL Location M ryl r) G 4- u� Cross Street Clty zi'p` mVrre(q arcel# q�.S�-03-010 <br /> PROPERTY Owners F - Lti -2 'aD IVL�ress-34 n , i /Ls\ 4.6 City 'll�,"/a I�f.(rtKlJP�Phone# /,2 9��'i6ul <br /> C-57 Contractor c+ - dress A/roi 'C1M Or city J,4,14 TjpLS20rLic#S IJ-l.(a?Phone# �.� 1,..7 5— <br /> Consultant/Sub Contractor U,-rn d I L-L Address/2<-- fit✓ city �^��° '�* Phonen'�1CS�.�l ��ya� <br /> GIs Coordinates:X Y ,Township Range Section <br /> WORK TO BE PERFORMED: DESTRUCTION 0058 type below <br /> u NEW WELL/BORING(CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER.OTHER-) pVEReORE ) �� <br /> aSOILBORING# (]PRESSURE GROUT f4 <br /> 'Other: DWELL# Grout Specificaters: <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFIC JTIAJT `/ <br /> MONFrORING U HOLLOW STEM DIA.OF BOREHOLE,_MULTIPLE CASINGS?]]YES 1r�NO WELL CASING DIA: a/ <br /> g EXTRACTION - 0 AIR HAMMERfDRNEN CASING THICKNESS TYPE OF CASING: 0 STEEL PVC Q OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL THEMETYPE TO BE USED: I]AUGERS 0 HOSE <br /> "R SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes I]No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> .01LBORING (]HAND AUGER GROUT SPECIFICATIONS= <br /> U OTHER: N OTHER APPROX.BORING DEPTH BOLTED TRAFFIC BOX or STOVE PIPE <br /> 1 / I CON UCTOR CASING PROPO ED?---��(If YES.SGt��mtlons here)- <br /> -COMMENTS: �k'/ /��1 l OrVKV 110 J�6.W�� ` l T <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT N INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared application and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rules ad R g rations, and all applicable California State Laws. <br /> Signed x Title/Companyy <br /> ?rim Name! A�tr�rA �QGFNGI-) I"1"i'n <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> 4ppYoetion AcceLd l . Dace Issued'rout Inspection Date Final Inspectiate)a0vetion InspeDate <br /> :OMMENTS!CONDRK)NS: <br /> ACCOUNTING ONLY' AID# cnrw <br /> CODES FEE INFO AMOU REMITTED CHECK A RECD SY DATE PERMIT t SERVICE REQUEST# INVOICE <br /> 1 1010, on �DO�D SR# OO <br /> C-57_ WC_-WAIVER_ C-57 Letter of Autho iz to sign permit_Encroachment doc_ 1/25/02 <br />