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07/15/2003 09 51 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> *�G 2 {3 ZD�3 � MITIGATION � <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ,,Ail, ENVIRONMENTAL HEALTH DEPARTMENT (EHQ) <br /> 344 E. Weber,Third Floor, Stockton, CA., 95202 <br /> (209) 4683449 <br /> NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FRom DATE ISSU> D <br /> Appricat3on is hereby mmi <br /> made to San Joaquin County for a pert to construct and/or install the worts described- This applicatl �s made In cgaspGance wnih San <br /> Joaqutn�County D vetopMent Tine,Chapter i 115 3 and the Standards of San Jo�u+n County Enwonmental Health Department--L <br /> epartment Assessors ��� <br /> --LId tRAb S'rf-lQ�- C MS— ! S �y�Parcel# <br /> WELL Lo6ffi nS•fs S-a.t •C�•,-k W [A'9W$s Street Cary �� �P <br /> City 23p Phone <br /> . . <br /> PROPERTY Owner C+ a Le D I Address <br /> verus,) t:fYr Aoseoiffer 5 678 � /OS'rrs �il6 Z86-SZGL <br /> ,,,f�, � 1-4d Add ss city Zip Phone# <br /> C-57 Contractor <br /> r Rear i Sz W ODa�l�ry ff t�G�#I►!tz Phvne�'O <br /> Cvnsuttdnt 1 Sub Contractor�e d d r`{ �- d s <br /> GIS Caordinates X <br /> Y Township 3 A Range ` 25— Section ! <br /> WORK TO BE PERFORMED DESTRUCTION(choose type below) <br /> NEW WELL I BORING(OPT GEOPROBE HYC)ROPUNCti,BAND-AUGER,OTHER) 13 OVER- <br /> ❑SOIL BORING# PRESSURE GROUT <br /> 0 W LL# Grout 5peatira4ons <br /> 'Other <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE GONSTRUCTIQN SPECIFtCAIONS <br /> (}MONITORING p HOLLOW STEM DIA.OF BOREHOLE _MULTIPLE CASINGS?[I YES 13NO <br /> WELL CASING DIA <br /> RTORING Q HO }.IOW ST /DRIVEN CASING THICKNESS^ TYPE OF CASING II STET=t IJPVC 1]OTHER l <br /> OR U MUD ROTARY DEPTH OF GROUT SEAL _TREMIE TYPE"!O BE USED Q AUGERS Q HOSE <br /> kR SPARGE f3 PUSH POINT GROUT SEAL PUMPED Il Yes p No (NOTE. MAXIMUM FREE-FA.LL DEPTH IS 30') <br /> l7 SOIL BORING I7 HAND AUGER GROUT SPECIFICATIONS <br /> (]OTHER Q OTHER APPROX.BORING DEPTH Q BOLTED TRAFFIC BOX or In STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,Inst speaficallons here) <br /> ` r <br /> *COMMENTS I - bs r • <br /> �o u ��� fa �. `` p�cs,.r� �Io •n <br /> J U e r ! *� <br /> NATE: OFFSITE BORINGS REQUIRE} ouRsCESS OR lN ADVANCE NaR ALL EQUiRED INSPECT<ONs <br /> CROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 46 W <br /> 1 hereby certify that l have prepared this appllCatton and that the work will be done in accordance with San Joaquin <br /> County Ordinances,Rules and Regulations,and all applicable California State Laws. <br /> Signed x <br /> vt Date $ l p O <br /> primed Name fVv-- s DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS' <br /> WORK PLAN DATED: "� `s Gj <br /> Date Issueda--,-'�—" <br /> Application Accepted$y Date_ <br /> Date Final Inspection By <br /> Grout Inspection By <br /> Destrucdon Inspection By Date <br /> COMMENTS I CONOrTIONS <br /> WACCOUNTINIG!IOINLY AID# rer�PE CODES =E�INFO AMOUNT R>:tN11TPD CH1=Ci(# RECID UY DATE PEIZMTr I SERVICE REQUEST 2 It+NQ10E <br /> SR# <br /> C-57 WC�,•-WAIVFR G-57 Letter of Authorization to sign permits,,,Encroachment doc— <br /> 112.5 <br /> f <br />