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FIFTH FLOOR <br /> 05/22/2002 13: 40 2094683433 • <br /> -" WELL PERMIT APPLICATION FORM SITE <br /> µ` MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRAM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a 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 County Environmental Health Department Assessor's <br /> 95Wq Parcel# ;�5a'-fSQ-IC7 <br /> WELL Location XH44 S Cross Street City IY Zip CC��,J�, <br /> J�n Pt�ild 6b�15 v��c �ItY Zip rhone#2Dsl-S3S-2St'II <br /> PROPERTY Owner v I-DGWNQ� Y rt dross <br /> / (Lo� ry rb>•k� p q 553 Nt�Phone#9x5.3 t 3-580D <br /> C57 Contractor bctA% k\\ Address �sy 1'�Ov�[ Ci �aCLZi 4 Lic# <br /> Consultant I Sub Contractcr S "� � kt 0�`�—Address <br /> 10'OyC�KS-�� City� Lic# Phone#�5-a99-93�� <br /> GIS Coordinates:X ,Y <br /> Township Range Section <br /> VVDyLX PERFORMED: 0 DESTRUCTION(choose type below) <br /> NEW WELL BORING(CPT.GEOPROF)E,HYDROPUNCH,HAND-AUGER.OTHER") []OVER <br /> 0 SOIL BORING# PRESSURE GROUT <br /> SWELL# J-IY <br /> GroutSpedilcations: G�t,nI- J0 <br /> 'Other: <br /> COMMENTS: <br /> TYPE OF WELL <br /> INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS �� <br /> MONITORING <br /> ',HOLLOW STEM DIA_OF BOREHOLE -1?11 MULTIPLE CASINGS?BYES ONO WELL CASING DIA: <br /> []EXTRACTION U AIR HAMMERIDRIVEN CASING THICKNESS S.1r[lj `117 TYPE OF CASING: 0 STEEL , PVC �OTHER'-_ <br /> 0 HOSE <br /> VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL St.t�7M[^CAS TREMIE TYPE TO BE USED: 11 AUGERS <br /> Q AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: ` Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING I7 HAND AUGER GROUT SPECIFICATIONS: Cts'[-[� ,pl_At 'p) ^"1 <br /> OF <br /> a OTHER: Q OTHER <br /> APPROX.BORING DEPTH YBOLTED TRAFFIC BOX or 11 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED 0 (if YES,list specifications here) <br /> V11 <br /> .a ` _I <br /> 41 Ao :s <br /> 'COMMENTS: a y 4 r . S Sµ <br /> NOTE: OFFSITE BORINGS R QUIRE <br /> HOIJRSGIN ADVESS ONCEENCROACHMENT <br /> FORALL OACR gUIRED IN3PECTSIONS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with S i n Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws, <br /> Title/Company J \ <br /> Signed x _ <br /> Date <br /> ----------------- <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FI E,ADDRESS: C✓21,_AP <br /> WORK PLAN DATED: Z �`��` / <br /> ` 1 Date Issued �z- Area <br /> Application Accepted By �'`1ti � pate <br /> Grout Inspection 8y <br /> Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FF-E INFO AMOUNT REMITTED CHECK 0 RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> Z 7 OZ <br /> D 1 �1 1/25/02 <br /> C-57— WC -WAIVER_ C-57 Letter of Authorization to sign pertrtit Encroachment doc_ <br />