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04/10/2002 1.5: 36 209468r FIFTH FLOOR <br /> PAGE 02 <br /> A EC1Eu\;;i IIID WELL PERMIT APPLICATION FORM <br /> SITE <br /> MAY 0 2 2003 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ENVIRONMENT HEALTH 304 E. Weber Third Floor, Stockton, CA., 95202 <br /> PERMIT/SERVICES (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM D $SUED <br /> Application 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,Chapter&1115.3 and the Standards of San Joaquin County Environmental Health De artrnent <br /> V(nz6 Mc Of�++J\.iv. 1)xy �d to\gr S1 til6v o Pl•r \'�y 4.3 Mien p1-030- <br /> WELLLoeation W"v a zt - S v S ° tv�„�leca I Cp�v� D:recl:�ip��" Parcel# tv�w-4 : 241- O- <br /> 11 earn.. P.L. 44-yo e.-w:n mo.,n\ecw, c-R 9s <br /> PROPERTY Owner t- 6o-c -ccs ' rens vv o Lir tr+, r33� <br /> 'Ci Tap Phone# <br /> C s7�nbacwrPreu\(cv Sct„ V_tiq L gddress i4ay S• 501+ Sk est City R:d w z Tp9ygp4 Uc#6 33l Phone#CstO)23�- 4515- <br /> 5'1 <br /> Consultant/Sub Contractor CHznn N1t.[- Address lSS tiYa.�,rl Age. Clry „�iLigf X33633 Phone#fs�o SSI--tS43!_o) <br /> A+��ciut#o Sw.ie\opo Ccn..kmcFors\,<cs.•,Le.) 91b -1t9-8582Lc: <br /> GIS Coordinates;X .Y ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL I BORING(CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) VAT15ES7RUCTION(choose type below) <br /> 0 SOIL BORING# •OVER$ORE <br /> ,IrWELL# Mw--A M.w-4 I)PRESSURE GROUT <br /> n <br /> 'Other: Grout Specifications: <br /> COMMENTS: N\o4 1'. . W.).5�. a�v.d.s-v�ynnx�!- uk t,nw-3 S:\e. <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ?\a ctn- AA¢ UrtASI. d' CLA6:c'� <br /> \,ZM0NITORING a HOLLOW STEM DIA,OF BOREHOLE MULTIPLE CASINGS?BYES 0 NO WELL CASING DIA:_ <br /> (f EXTRACTION - a AIR HAMMEMDRrVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC B OTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS 0 HOSE <br /> "R SPARGE 0 PUSH POINT GROUT SEAL PUMPED: O Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> .OIL BORING 13HAND AUGER GROUT SPECIFICATIONS: <br /> 0 OTHER.-______n OTHER APPROX BORING DEPTH 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list specifications here): <br /> 'COMMENTS: A'±c i,wOE Anz4n�+r�� v,nn 4i,.c� .:,iQ C +n� a� - B � •� n H•.r �e�41l <br /> �d <br /> 9A r <br /> ls •4EM4�r <br /> NOTE: FFSORINGS EQ <br /> I BUI E ACCESS OR ENCROAC ME PERMITS:f� 006--C­--� <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepar�this application and that the work will be done in accordance with San Joaquin <br /> County Ordina es,RU t�a egulati a applicable Califorrial State Laws. <br /> Signedx �7 Tille/Company (�,PDSL-C% (i Y�/�)�re�COGfS T <br /> Prim Name /�J GC GcJ ry�1�/✓Ci/(T(O Date <br /> DEPARTMENT USE ONLY / <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATI=b- <br /> Application Accepted By Date Issued // lu ( � ✓ grpa "� <br /> Srout Inspection By oat Final Inspection By Dat `J <br /> )estruction Inspection B ate <br /> :OMMENTS/CONDrrIONS: <br /> ACCOUNTING ONLY,. AID# <br /> carve <br /> .CODES FEE INFO AMOUNT REMITTED CHECK# RECD B7 DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 12 o SIR# <br /> C-57� WC=WAI C-57 Letter of Autho izati n 0 <br /> sign permit_Encroachment doc_ 1/25/02 <br />