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09/13/2004 12: 43 2094683 FIFTH FLOOR ' PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> SAN JOAQUIN COUNTY LOP SITE <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) MITIGATION. <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> NDABLIP PERMIT <br /> UH�CM PAM ISSUED <br /> Application Is hereby made to San Joaquin County for aperrmit to Construct and/or install PIRES I mg Work described. This appllratlon is made In compliance with San <br /> Joaquin County Development Tltle,Chapter 9-1115.3 and the Standards Of San Joaquin County Environmental Health Department <br /> WELLLOcation�5ab G� Q(4A ss Street E'leve.,4k $-1'-e'Ci �''v �c� qc�,,u Assessors <br /> PROPERTY Owne! 1 ry �p'` Pa�M-- 50- 1 O -t,"3 <br /> �,s:�/�vore� Address$(zQlr:�t.�u IIS R i C;ty z �r <br /> ��-y P q 53i)Phone# ACli- 60'1- i� <br /> cal Contractor—S jKR �e -"-C tt;S T c' T -- — <br /> �ddress_I30ti9 r-4�+FI mrYL pue <br /> v City vi' Top°IOb70Lic#�N2Qi Phone#5G�-olb3-w55 <br /> consultant 140b Cntr ()L',5 car par a4,"V'Address�g7a GrJeii r ( L C <br /> GIS CooMh Ljinates:X S+�nc�m <br /> rh` � cn ' Phone#91 b-b'xt-aoc0 <br /> Y Township Range Section <br /> WORK TO B PERFORMED= <br /> p NEW WELL <br /> WR <br /> ORIN GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) p DESTRUCTION <br /> O'SrO11.B - 12, (choose type below) <br /> aWELL# 11 OVER-BORE- DIAMETER <br /> n`Outer B,PRESSURE GROUT.-�o�,kxy�3�,n vj,,,,,.,g <br /> COMMENTS: N C ,e- irs F i\Qd GROUT SPECIFICATIONSS; <br /> TYPE OF WELL INSTALLATKMN TYPE CONSTRUCTIONSPECIFICATIONS <br /> 11 MONITORING 11 HOLLOW STEM DIA-OF BOREHOLE_ 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> Il EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNE$$ <br /> 0 VAPOR TYPE OF CASING: p STEEL p PVC p OTHER: <br /> Q MUD ROTARY DEPTH OF GROUT SEAL <br /> p AIR SPARGE OZONE TREMIE TYPE TO BE USED: Q AUGERS riuSErPVC <br /> p�bUSH POINT(GP car C II GROUT SEAL PUMPED: C Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> V!5OILBORING BHAND AUGER / GROUT SPECIFICATIONS' <br /> Q OTHER:. II OTHER APPROX BORING DEPTH <br /> O BOLTED TRAFFIC BOX Or Q STOVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED (U YES,list specifications in Comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application 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 pU+'1 ��-l�f -_Title/Company n.'QC-+ <br /> Print Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: / <br /> v <br /> Application AcceptedBy ..-�a-e f, Date Issued Z- 0 <br /> Grout Inspection By �Wz Are <br /> Final Inspection By te - <br /> Destruction Da2 <br /> ion Inspection By - <br /> COMMENTS/CONDITIONS: .d <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# <br /> RECD BY DATE <br /> 'Ol Fo/ - PEFU9fflSERVICEREQUEST# INVOICE <br /> 3�766Z <br /> C-57 WC <br /> -WAIVEP. C-57 Letter of Authorization to sign permit Encroachment / <br /> 9/30/02 <br />