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/10/2002 15:36 20943 FIFTH FLOOR d 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 D&CE ISSUED <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 9-1115-3 and the Standards of San Joaquin Countyry Environmental Health Department <br /> w <br /> 4.3 kkti, no i� o�liwy tzo e,,. Nr or %z" c,(A h X. 5 y� Ltev se X44 01v a Assessoris s <br /> WELLLoeation Pt Z 6 Mc M rt ,, •I 4TAThnh.1 Cross Street City Zip Pass 03-21 <br /> PROPERrYOwner PGe F LinA, - C'1ons"eSAddress 3-15 N. Mc\5ek Ln Ctly- -my CTtOZP 94598 phone# 925-9"1 L; 4D8 I <br /> C37 Contractor $ c rn EX r4lioMddress 2305 W�awaw�� UYLJc_ Ci StiockFv Zi 95 005 1=( � b p Ix#51i16�Phone# 109-465- 9-11-L- <br /> Consultant/Sub <br /> Consultant/Sub Contractor CF11M 4lILL Address tSOi AMew> Clry Oa�c 3p�133633. Phone#SIV-%1 " -ISBS <br /> F�pn'"r,++r"313i�oj •�n:c.m�,.�1.v.yu, <br /> GIS Coordinates:X Y ,Township Range Section <br /> W RK TO-BE PERFORMED: <br /> WELL BORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER.OTHER") p DESTRUCTION(choose type below) <br /> 0 SOIL BORING# ()OVER-BORE <br /> VQWELL# I NEVI MONITORINfWgLL a PRESSURE GROUT <br /> 'Other: Grout Specifications, <br /> pedtca ions: <br /> TYPE OF WELL IN TALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING Vij HOLLOW STEM DIA.OF BOREHOLE_,MULTIPLE CASINGS?N YES W40 WELL CASING DIA:Z SCD N'D PVG <br /> Q EXTRACTION - Q AIR HAMMER/DRNEN CASING THICKNESS TYPE OF CASING: Q STEEL �VC THER; <br /> 0 VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: AUGERS B HOSE <br /> 'IR SPARGE p PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> .OIL BORING II HAND AUGER GROUT SPECIFICATIONS: NbAT PORTLAND CEMENT <br /> 0 OTHER. n OTHER APPROX BORING DEPTH II BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,list spedFlcations here): <br /> 'COMMENTS: fle>L n t'Ho r•),,,A_. ...e t t c - uIl0 1:LQ r+. <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 Ordinances les aa9d tions, and all applicable California State Laws. <br /> Signed x �l�'l�����j1 +� Tite/COmpany / S Cl YIJA/ i',r���t'r�5 i / rf ZYR16- <br /> .Nnt Name ����0 1 G;q A. /C/,f( T%() <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: CJ J <br /> k9plication Accepted By. '/ ' L'1 Date Issuod (: f/°J�v Aroa <br /> Smut Inspection 81' % Date Ftnal Inspection By Date <br /> )estrvo6on Inspection By q2te <br /> :OMMENTS/CONDRIO I <br /> ACCOUNTING ONLY: AID# <br /> cerw <br /> !CODES FEE INFO AMOUNT REMITTED CHECK 0 RECD Y DATE PERMIT I SERVICE REQUEST N INVOICE <br /> ill Wdz sR# <br /> C-57_ WC=WAIVER_ C-57 Letter of Autho iza on t sign permit_Encroachment doc 1/25/02 <br />