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12/10/2002 10 10 2094693433 FIFTH FLOOR PAGE 02 <br /> ------------ <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 30+4 E. Weber, Third Floor, Stockton, CA., 95202 j <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the work descnbed Thr,applfcation is made,n compliance with San <br /> Joaquin County Development Title Chapter 9-1115 3 and the Standards of San Joaquin County EnvlronmentaE Health/ Department <br /> _ !rr Assessors <br /> WELL Location 131'_l .6'j- G c r+ej�,Cross Street f r +ty a!lo^ Zip 9SZQT Parcel►! IS 70A <br /> — 7 <br /> PROPERTY Owner !r 1.✓rIti t� _Address P,D. 9�4 x -x-53 2 Z City,��1c�a� ,p 9SZfaPhone#2 $ r►` <br /> C-57 Contractor Gecgc Address !?S-O ,ir l City Z+p YS53 Lac#5`�y�Phonat+�ls 3y-�'SgUo <br /> Consultant/ address o er�C r, �r rCity� L,Gf Phone# 7a - '3-2369 <br /> GIS Coordinates Y ,Township Range Section <br /> WO!3K TO BE PERFORMED <br /> XNE ELL DRING (CPT, GEOPR06E,HYDROPUNCH HAND AUGER,OTHER-) p DESTRUCTION (choose type below) <br /> U-SOIL BORING# [JOVER-BORE DIAMETER,.,,-, <br /> ,WW ELL# ice- 't b PRESSURE GROUT <br /> 0-Other GROUT SPECIFICATIONS <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIF1CATt_O_N_5 If <br /> MONITORING ftA IOLLOW STEM DIA OF BOREHOLE_✓ (]MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA <br /> a EXTRACTION [I AIR HAMMER/DRIVEN CASING THICKNESS -TYPE OF CASING a STEEL {,>VC (I OTHER <br /> WOR ❑MUD ROTARY DEPTH OF GROUT SEAL ^'6 rTREMIE TYPE TO BE USED AUGERS 'HOSE <br /> PARGE/OZONE [l PUSH POINT(GP or CPT)GROUT SEAL PUMPED )rre9 [)No (NOTE= MAXIMUFREE-FALL DEPTH IS 30') <br /> ©SOIL BORING []HAND AUGER GROUT SPECIFICATIONS Cel"'— <br /> OTHER—[] <br /> el"'— <br /> OTHER []OTHER APPROX BORING DEPTH_ �ec OLTED TRAFFIC BOX or E STOVE PIPE <br /> CONDUCTOR CASING PROPCSED tyQ (+f YES,Inst specghcationc in comment sector) <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 I have prepared this appltcatlon and that the work will be done in accordance with San Joaquin <br /> County Or lations, and all applicable California State Laws <br /> Signed x r'14z Titfelcornpany U �� ��•` <br /> Print Name ��^ aye Date / z s- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS: <br /> WORK PLAN DATED: n rJ� / r1 <br /> Application Accepted By l R Dato Issued �G r O ZOO� Area_ <br /> Grout Inspectlon By Date Final Inspection By Dare <br /> Destrucuor Inspection By Date <br /> COMMENTS I CONDITIONS <br /> ACCOUNTING ONLY AID# FAC# <br /> ,ODES FEE INFO AMOUNTREM117D CHECK# REC'D Y 1DATE PERMIT I SERVICE REQUEST# INVOICE <br /> S—� rD r� oZ SR# <br /> f <br /> C-57 WC -WAIVER C-57 Letter of Autho �cl <br /> o sign permit Encroachment doc 9!30!02 <br />