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SEP-10-03 "WED 02 :23 PM ENPROE <br /> 9165892230 P. 02 <br /> 0 Z002 <br /> 09/10/2063 13: 26 FAQ 923 943 2966 <br /> GE0SYNTEC-ITC <br /> WELL PERMIT APPLICATION FORM Y SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third 9 )3449 or, ton, CA., 95202 <br /> �=FUND A@LE PERkIrC FYDIRE&1 YEAR FROiVI DATE ISSQ <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor Install the work described. This appfioetion is mAssesse in oors p/Illance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of SEA Joaquin Count rwQlron�en H Z'p q S LD`en Pssessrcer <br /> (`61 S • Ar o r\CLxz+ 5L Cross Street }¢w —L'ty -- <br /> WELL Location ort <br /> in a S t Phone# LC°l'jk4'X77 r <br /> PROPSF�T�( (��}'�i r�Address ro"` 5 • r ono"'i S City 9i`— _ <br /> J ole rdo r >— 77711D7PhoneK �J <br /> Owner_ l eV Zip9S�(,6LI <br /> pn,lo Address if. (�41C 60A) (illy o� <br /> C•57 Contractor-A �I���,,1 u Llc _ Phoned C1�S-' q j�3Q 3�1 <br /> o�c n � Address Isa A) ,, Il reek <br /> Consultant/Sub CnV^ ,�;{L f(oo Section --- <br /> Township Range .-_-_-- <br /> GIS Coordinstes:X ___.� `Y-----' <br /> {(YORK TO BE PFRFPRMED L)ESTRUCTION (Chcose typo below) <br /> )NEW WELL BORING (CPT, OPROB ,tIYDROPUNCH,HAND AUGER,OTHER`) OVER-BORE. DIAMETER <br /> r� jjes0tLBORING# pRESSURE GROUT <br /> L-WELL# GROUT_SPECIFICATIONS <br /> (3`othel ��b - �o �l"4.j, r j" <br /> COMMENTS:_ bogy),e <br /> LATI GONSTRUCT10N CpECIFICATIONS <br /> TYPE YVELL DIA.OF BOREHOLE__ t]MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA• <br /> a <br /> MONITORING p HOLLOW STEM <br /> TYP£OF CASING: Q STEEL I]PVC 0 OTHER: <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TREMIE TYPE TO BE USED: p AUGERS 0 HOSE <br /> E VAPOR 11 MUD ROTARY DEPTH OF GROUT SEAQ <br /> 0 USH POINT(GP or CPT) SEAL PUMPED: Oyes Q Na (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> AIR SPARGE/OZONE <br /> ` ,$OIL BORING 0 HAND AUGER GROUT SPECIFICATIONS__ -- BOLTEO TRAFFIC BOX or 0 S <br /> 0 OTHER:P _ p OTHER _ APPTOVE PIPE <br /> rROX.BORING DEPTH 0 ,f YES,list spacincations In comment section) <br /> '�'�1 �J �! CONDUCT R CASING PROPOSED_ <br /> COMMENTS,. 1 v `��! `� �1"gr <br /> NOTE, OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> -' 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify th ave p spared this application and that the work will be done In accordance With San Joaquin <br /> County Ordtnan s utas d R ulatlons, and all applicable California e Laws, <br /> � 7tttefCompany_� ���'��r J <br /> Signed>< <br /> _ --Dale— <br /> Print <br /> —Daca_ <br /> PrintName � - — DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, D RESS: GTt�� <br /> WORK PLAN DATED' S <br /> Application Accepted B ti^A/i[t - r I <br /> Date Issue O� _Are,, 3� <br /> Grout Inspection By Ind rw� _Gate Z 3 O Final Inspection By(( ^y^S�=_ Dato 3 O <br /> Destruction Inspection By DEte - <br /> COMMENTS ICON DITIONS' <br /> ACCOUNTING ONLY: All?# _ FAC# <br /> PL,CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DA E PERMIT I SERVICE REQUEST# IN ` <br /> �Ci o0 3s� 03 <br /> C-57_____ WC -WAIVED_ C-57 Letter of Author to sign permit Encroachment docs 30/02 <br />