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05/15/2003 14 06 2094633433 FIFTH FLOOR PAGE 02 <br /> FD) CEVED <br /> FILE COPY <br /> WELL PERMIT APPLICATION FORM SITE <br /> APR d S ��a3 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRORMENT HEALTH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> r PEPWIT/SERVICES 304 E Wever, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> P � NON-REFUNDABLE PER1ULEXPIRES 1 YEAR FROM DATE 15SUED <br /> Apptleatlon is hereby made to San Joaquin County for a permit to construct andlar Install the work described This application Is made rn=mpltance with San <br /> Joaquin County DevelopmentTltle,Chapter 9-1115 3 and the Standards of San Joaquin County Environmental Health Department. <br /> `.a Assessor✓ <br /> WELL Locatio N� �u� 6 oss Street tS$ CityS Zlp Parcatk <br /> PROPERTY . '• LO(JN pII �`, q <br /> Owner � Addre-_- 4 iTIty� �3�J up Phone�j��� ( LrDGO,,c ��r <br /> C 57 Contractor ( Address City 2ipiaPhone# <br /> iConsultant/Sub Cnhr e, Address L' O �A Ljc4 Yv Phone a? �� r <br /> GIS Coordinates X _1Y Tovmship Range Section <br /> ' WORX TO BE PERFORMED <br /> Q NEW WELL.I BORING 0 GEOPROBE WMPOPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION (choose type below) <br /> 9 SOIL BORING p OVER BORE DIAMETER <br /> p WELL# PRESSURE GROUT <br /> 0"Other r .J_ G UTr� LuJ <br /> PECI ICAT10 S <br /> COMMENTS r l5 .�.t ti ktC <br /> TYPE OF WELL INSTALLATION TYPE CONSTItLICTION SPECIFICATIONS <br /> Q MONITORING 0 HOLLOW STEM DIA OF BOREHOLE7a MULTIPLE CASINGS Q MULTI-LEVEL AELIa,�GASING DIA, <br /> Q EXTRACTION Q Alfa HAMMER/DRIVEN CASING THICKNESS Y `' F�TYPE OF CASING STEEL 0 PVC��0 OTHER <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL MIE E TO BE USED Q AUGERS 0 HOSE <br /> Q AIR SPARGE/OZONI� POINT(GP or OPROUT SIAL PUMPED Q s 13 No (N AXI UM FREE FALL EPTH 15 30') <br /> 0 SOIL ROPING ��vvvVTTa HAND AUGER GROUT SPECIFICATIONS u <br /> ' Q OTHER Q OTHER. APPROX BORING DEPTH Q 9OLTED TRAFFIC BOX q,,k STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (d YES,fat speci6cabons 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 certl at l h e pre red this application and that the work will be clone in accordance wt t Sari Joaquin <br /> ' County Ord a ces, les an Regulations,and all applicable Callforn tate Laws _ <br /> 5lgned x TitlelCompany a r� <br /> Pint Name <br /> Date <br /> DEPARTMENT USE ONLY ! } <br /> SITE MAP IN UNIT IV FILE, ADDRESS: t rLL .r r � -- <br /> ' WORK PLAN DATED <br /> Application Accepted By Date Issued ID-o�.ElVVlRONlIIE <br /> Grout Inspection 9y Date Final Inspection By C e <br /> Destructton Inspection By Date <br /> COMMENTS 1 CONDITIONS —a3"� fo r <_ <br /> _ <br /> ACCOUNTING ONLY AID#, FAC# <br /> PE COE]ES FEE INFO AMOUNT REMITTED CHECK# REC'D 13Y DATE PERMIT l SERVICE REQUEST# INVOICE <br /> ' ).go tl X03 4- e, SRS 33 3 <br /> C-57-.,,/ WC -WAIVER_ C-57 Letter of Authorization to sign perri;tt_><ncroachment doc 4/30/02 <br />