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01/03/2003 14:18 209468 `3 FIFTH FLOOR PAGE 02 <br /> 'e1 NOOK <br /> a WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> F c B 1 g 2003 ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E-Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> F'`r' <br /> NON-R FUND L PE MIT ES 1 YEAR FROM DATE ISSUED made San <br /> Application 1S hereby rnado to San Joaquin County for a permit to construct andlor install the work described- This application is made in compliance <br /> Joaquin County Developmenl.711s,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. ssessors N A <br /> wELL Location NAg4 E)21UE-1 Q16tf7(�f W- Cross Street Ae.Gor+AuT City <br /> S i OCKT��l aP �`�� Parcel* <br /> erCt� OF SToG�fTa1J Addressg2� N. EL DoQADo S'C•CitySTOCKror-A 9�✓�ZPhone#(Zo9�937-s3`�I <br /> PROPERTY own" <br /> `� 95 Lic1R?t75to Phon�9Kv�638-ttto°) <br /> C-67 ContractorepSc of j)(latj-tr-i(; ddress3b32 �M Ec Ci Rcr.E city k^tjc �P `{- <br /> ConsultanelSubCntr�EOTopN IntC. Address3o PaosPis cityco�2A Lic# -y 99 Phone#CQ►ro)t3S3^tom <br /> RRA mvie- Range (o� Section00NE DIVF,n1 <br /> GIS Coordinates:X Y Township 1 L <br /> WORK TO 13E PERFORMED: <br /> TRUCTION (choose <br /> HND-AUGER,OTHER-) belotw <br /> pNEWWELL/BORING (CPT,GEOPROBE,HYDROPUNCH, OVER-SORE- DIAMETEi0 <br /> [�SOIL BORING 1f D PRESSURE GROUT <br /> DWELL# GROUT SPECIFICATIONS NCf ConAer- y <br /> D"Other <br /> COMMENTS: Q%4 <br /> DILQF INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING Q HOLLOW STEM DEA.OF BOREHOLE D MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 'TYPE OF CASING: p STEEL D PVC (IOTHER: <br /> 13 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE TO BE USED: D AUGERS Q HOSE <br /> Q AIR SPARGE/OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yas D No (NOTE: MAXIMUM FREE-FALL DEPTH 1S 30-) <br /> D SOIL BORING D HAND AUGER GROUT SPECIFICATIONS BOLTED TRAFFIC 60X or D STOVE PIPE <br /> a OTHER: D OTHER- APPROX.BORING DEPTH d <br /> CONDUCTOR CASING PROPOSED (f YES,list specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AC3REEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin nces, Rules an Regu tions, and all applicable California <br /> -State Laws. �^ <br /> Signed x Ttle/Company Jr ►�- `"1 D"F IST /0116D/t`U�7`1 <br /> Date <br /> Print Name, <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: �- C <br /> -r Date Issued d Are <br /> Application Accepted gY ` <br /> Grout Inspectlon By Date Final Ins Ilion y Date <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITiO <br /> ACCOUNTING ONLY: AID# FACT# <br /> PE CODES FEE INFO AMOUNT REMITTED CHEGK# REC'D BY DATE PERMIT/SERVICE REQUESTi INVOICE <br /> 3 so 0 1�� 1 a ( A3 SR# 3 <br /> C-57_ WC -WAIVER-- C-57 Letter of Authorization to sign permit_Encroachment(10C— 9/30/02 <br />