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01/03/2003 14:18 2094E,,..W33 FIFTH FLOOR N%EW PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> F E 8 1 8 2003 304 E.Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> _i".�,I,,:_i`vr._�: . _ •;LII, <br /> FAR FROM DATE ISSUED <br /> NO.-REFUNDABLE PERMIT EXPIRES 1 Y <br /> Application Is hereby made to San Joaquin County for a permit to construct andlor install the work describQd. 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 Hoatth Department <br /> Assessors <br /> WDLL Lo=tlon /III I'�A•/y DRII(€ Cross Street AW ofJAU, Clty S-rocyc�or4 ap 95202 Parcel# I(o32(oDo� <br /> P e,Wx 12 515(.0 <br /> PROPERTY Owners FkC" FARMS Address?0Z E N.714 6 /�V 95 —City �Rc5N0 Zlp 93 Phone Cs ��8�'2310 <br /> RAtjCHO <br /> C-57Cant-actor CAg'ADS Address3&932 OM EC Ct2CLt: CitycoR4WA Zip9571421rc#!17510 Phone#C91l92(-03-0 109 <br /> RANc"o <br /> Consultant/Sub Cntr nI-oTRotrt3 SNC. Address3o35 ytL.PA.0%?C.0 - citCo0%& Lict1 y� „Phone#C9tto)853-t820 <br /> GIS Coordinates:X Y PAR T�Rh p 1 t4Range_ li Section NONE -21V EI\I <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROeE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type below) <br /> ]]SOIL BORING# OVER-BORE. DIAMETER <br /> p W ELL# p RESSURE GROUT <br /> D*Other GROUT SPECIFICATIONS NEAT CEMtdEF <br /> COMMENTS: nyE.R 60 tAVJ 4 T.0_ 35, BGS A-,�4n 10"05 AUGEP <br /> A 2E: ,, PVC. [SRN �*T- CEMer-4T ". <br /> TYPE OF)YFLL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING C HOLLOW STEM DIA.OF BOREHOLE 1]MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA: <br /> 13 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: p STEEL 0 PVC Q OTHER: <br /> U VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: p AUGERS p HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yas a No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> U SOIL BORING (]HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER;_O OTHER APPROX.BORING DEPTH 0 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (f YES,list specifications in comment section) <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 application and that the work will be done in accordance with San Joaquin <br /> County Ordi noes,Rules and Regulations, and all applicable CalifornianState Laaws. T <br /> Sign <br /> Title/Company �C:1ylC� 67 L rte` �S <br /> Print Name Date Z 11-7 �3 <br /> DEPARTMENT USE <br /> cO/NLY <br /> SITE MAP IN UNIT IV FILE,AD RE J T� <br /> WORK PLAN DATED: / 7 <br /> Application ACceptod By Date Issued '-��d3 Area <br /> Grout Inspection Sy at Final on Dato <br /> Destruction Inspection By at <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AIDii FAC# ` <br /> PL'CODES FEE INFO AMOUNT REMITTED CHECK# RECD BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 330 /,:71-7 21 k3 SR# 0 <br /> C-57_ WC_WAIVER- C-57 Letter of Authorization to sign per Encroachment doc 9/30/02 <br />