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/10/2003 13: 26 FAX 925 943 236610 GEOSYNTEC-TC Z002 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON REFUND(]@l E PEghlrC FXPIRE�1 <br /> RF DATE IS6m <br /> �ppllcation Is hereby made to San Joaquin County for a perm( stall the work described. This application is made In compliance with San <br /> caquin Counry Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department.Asseacors <br /> S. �laj 0 rt0.w� I r L Crf _Crow Street ��"',y_`-'ity� 0 C n Zip 4 S 10 C Parcern <br /> DELL Location_ <br /> >ROPE rr r- s rgono�v� City FtCO�Zip g6bZ Phone# lOq-Iit4-9Y'"li <br /> owner���0`�+l°! rt�cZ���$�Addn:ss <br /> l <br /> r a ! <br /> �.57Co�traclor „ro� address Q �OY. bQ�j <br /> city OV;�­11 Zip ISYULic#777/07phone# X1 0- y ��7Olq <br /> consultant/Sub Cn(r_ l9Go�4�l c Address l doe WClty�' k-1 4 Llc# Phoria# <br /> wt�t yc° r[ek <br /> GIS Coordinates:X <br /> Y ,TownahlP Range Section <br /> NORK TO BE PERFORMED; <br /> NEW WELL/BORING CPT, OB Vyl)ROPUNCH,HAND-AUGER,OTHER`) VESTRTION <br /> D AVER BORUCDIAMErER oose type below) <br /> # D PRESSURE GROUT <br /> UI YELLOtL BOR1N0# --- GROUT SPECIFICATIONS <br /> D'Other ♦ 7.fi�'lOn0. �rle i 9t gfrN� OI�Otav����rr Sd�m_dl-0 S <br /> COMMENTS:- <br /> TY P E <br /> OMMENTS:_TYPE Q;WELL INSTAI_LATt_ON TYPE= CONSTRUCTIONSPECIFICATIONS <br /> q MONITORING D HOLLOW STEM DIA.OF BOREHOLE_- D MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA- <br /> EXTRACTION AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: p STEEL p PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL TRENIIE TYPE TO BE USED: D AUGERS 0 HOSE <br /> D AIR SPARGE/OZONE RUSH POINT(GP or CPT)GROUT SEAL PUMPED: p Yes o No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> FOIL BORING D HAND AUGER GROUT SPECIFICATIONS_ <br /> p OTHER:__[]OTHER _ APPROX.BORING DEPTH BOLTED TRAFFIC BOX or p STOVE PIPE <br /> *CN T R C PROPOSED (if YES,list specifications In comment section) <br /> COMMENTS: EAT ��c1i! <br /> NOTE: OFFSITE BORINGS REACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify th ave p epared this application and that the work will be done in accordance with San Joaquin <br /> County C roan s "IeSL d R ulations, and all applicable California State L ws. <br /> 1 l <br /> Signed x Tille/Company ���) <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,A j] ESS:_ JSJ I <br /> WORK PLAN DATED: S _ <br /> Application Accepted By Date Issued I I <br /> Grcul Inspection By. _Date3 Final Inapection By Dale Z <br /> Destruction Inspection 8y Dete -- <br /> COMMENTS f CONDITIONS: <br /> ACCOUNTING ONLY: AIDE/ FAC# r� <br /> LPLCODES FEEINFO AMOUNTREMITTED CHECK# REC'D BY DATE PERMIT I SERVICE REQUEST INVOICE <br /> q 3 5 n X 03 sR# 3 -7, <br /> C-57-- WC---WAIVER____ C-57 Letter of Authorization to sign permit_,_•,Encroachment dot„"- 9/30/02' <br /> tt� <br />