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05/15/2003 14 06 2094633433 FIFTH FLOOR PAGE 02 <br /> laEF��V' n FILA OPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> APR 0 S 2003 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRORMENTHEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> ' PEPNIT/SERVICES 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 } <br /> rNON-REFUNDABLE PEFtMrr EXPIRES 1 YEAR FROM DATE 1S5UED <br /> ' Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This applicatlon Is made in compliance with San <br /> Joaquin County Development Tltle,Chapter 9-1115 3 and the Standards of San Joaquin County ErNironmental Health Department. J <br /> ASSESSOrS <br /> WELL Locator N-F'4-4H6 ss Street LSs CityS ZIP �arcet# <br /> E rr t� <br /> ' PROFIERTY6.S• CDr�P ����� i } bPhone# <br /> Owner Address ty p 1/d{J <br /> C 57 Contractor I I Address City Z�piJJlac�phon®# 2Q1 <br /> ' Consultant/Sub Cnir +✓ Address �f Cit�,Lte# Phone <br /> GIS Coordinates X Y Township Range Section <br /> ' WORK TO BE PERFORMED <br /> 0 NEW WELL.!BORING CP GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION (choose typo below) <br /> D SOIL BORING# j]OVBR BORE DIAMETER <br /> p <br /> WELL <br /> # .PRESSURE GROUT <br /> a*Or G UT PEC! ICAMO S <br /> ' COMMENTSthsr f r I ''' '"' �}!J <br /> r <br /> TYPEF WELLINSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> o MONITORING a HOLLOW STEM DIA OF BOREHOLE Q MULTIPLE CASINGS p MULTI-LEVEL QqELI�CASING DIA <br /> iiiii0liEX7RACTION p AIR HAMNERIORIVEN CASING THICKNESS r "�TYPE O*CASING STEEL Q PVC��p OTHER <br /> APOR 01MUD ROTARY DEPTH OF GROUT SEAL TO BE USED p AUGERS Q HOSE <br /> pAIR SPARGFJ OZON POINT(GP orq&ROUT SEAL PUMPED A []No (NI UM FREE FALL EPTH IS 30') <br /> SOIL BORING Q HAN❑AUGER GROUT SPECIFICAT10N9OTHER Q OTHER, APPROX BORING DEPTH D TRAFFIC or hRTOVrz PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,Est speutfoatiens In comment aectian) j <br /> COMMENTS <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS, <br /> I hereby cklacesilesan <br /> e pro red this application and that the work wtll be done in accordance wit San Joaquin <br /> ' County OrRegulations,and all applicable Cailforr► tate Laws <br /> Signed xTitlelGompany e.J [ f <br /> ' Print Name <br /> Date <br /> DEPARTMENT USE ONLY j <br /> SITE MAP IN UNIT IV FILE, ADDRESS: GZ N r F1gAAq'"�' <br /> ' WORK PLAN DATED' <br /> y Date Issued <br /> Application Accepted BI�—t��.ENV�RONNI <br /> C <br /> ' Grout Inspecdon By Data Final Inspection By .� <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS ^3r- 3g7-d—? (.G� <br /> ' EACCOUNTING ONLY AEC]# FAC# <br /> S FEE INFO AMOUNTREMITTED CHECK# REG'D SY DATEPERMIT 19SRVICE R1"QUEST# INVOICE <br /> sR# <br /> I <br /> ' C-57 WC_ WAIVER C-57 Letter of At4thorixatlon to sign permit_Encroachment doc 9/30/02 <br /> I <br /> I 1 <br />