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02/27/2003 10:07 FAX 209 94,4111171 PHS RHD IM002 <br /> 02/27/2003 08:09 209468_1. FIFTH FLOOR • PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EMD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NUN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicaflon Is hereby made to San Joaquin County for a permit to construct and/or install the work described, This application is made in compliance wlth San <br /> Joaquin County Development Title,Chapter-9-1115 3 end the Standards of San Joaquln County Environmental Health Department <br /> WELL Location d Assessors <br /> a�i1 +aw A71• Cross clyLD rp �j Parceln042-D`m�/-/O//!3 <br /> PROPERTY OwnerGA� Address62//O/r+i1 Ci f YI���ir/�' 7Phone#7/7!- �7 f * <br /> C•57 Contractor��Q /1 Addres 'f e ` /� ,J CityZipokL LicYf� Phone# b%_ T/z <br /> Consultant/Sub Cntr &khA �/�_Addresses 27 , /4�`//Z Cit!!_Uc# Phone# <br /> GIS Coordinates:X ,Y ,Township�,�_Range FBF— Section ` <br /> WORK TO BE PERFORMED: <br /> )'N1=W ELL I BORING (CPT GL ROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> 6OIL BORING# �2� 3 aOVER-BORE DIAMETER <br /> n WELL# [I PRESSURE GROUT <br /> ( 1Other_5iµaL IdbZ t dLNy I GROUT SPECIFICATIONS <br /> COMMENTS: JJ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SP IFICATQNS <br /> H MONITORING p HOLLOW STENT DIA.OF BOREHOL ' []MULTIPLE CASINGS 0 MULTILEVEL WELL CASING DIA' ,�� �" <br /> 0 EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS MI'f— TYrPL OF CASING: 0 STEEL 0 PVC 0 OTHER:_�F� <br /> 1]VAPOR OMLID ROTARY DEPTH OF GROUT SEAL I2'�ca5a.lf T4rQEEMIE TYPE 70 BE USED: (,y,�,,'1�GERS�/?'�''OSE <br /> O AIR SPARGE/OZONE�HPOINT(GP or CPr)GROUT SEAL PUMPED: p s No (NOTE: MUM FREE-FALL DEPTH IS 30') <br /> L BORING X3 aHAND AUGER �' K l GROUT SPECIFICATIONS W �eslwfj <br /> OTHER: Q OTHER APPROX.BORING DEPT 20 f n BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOS D Of YES,list spocifications in comment 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 4jlave pro Oed application and that the work will be done in accordance with San Joaquin <br /> County Ordinan u e Re tions, and all applicable California State Laws. r <br /> Signed x _ Tifle/Company = /� 1q— C� "�-- <br /> Print Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted Dy Date Issued Area <br /> Grout Inspection By. Date Final Inspection By Date <br /> Destruction Inspstuon By Date <br /> COMMENTS!CONDITIONS: <br /> ACCOUNTING ONLY, AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKS RECD BY GATE PERMIT/SERVICE REQUESTYf INVOICE <br /> $R# <br /> C-57 WC -WAIVER, C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />