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07/14/2003 14:01 9168610 SECOR PAGE, .02/n ' <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(END) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 46$3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR RO DATE_1S5UED <br /> Application is hereby mads to San Joaquin County for a permit to construct and/or Install the work described. 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 Health Department <br /> Zy25' Laun�r C-Lub 8+va p s2-o4 'Parcew Z <br /> WELL Location � erose street �2 city St�k�t-on Zip a l-o3o-�J <br /> PROPERTY <br /> Owner - levein, ,nC, Address P,0, Neo(, -7II City IDd1I4S,'ffZIp 7--2.21 Phoma## <br /> RA V%4K6 fZslbPhone# q16 r b� <br /> C-67 Contractor GaSGadQ dr,���nq Address 363 OMAC G.r Clty Cor acyq ZIP-2$7 uc#,]_ — <br /> loo Qw`Gl.o <br /> Consultaan11SubCntr SECo(R r-n+CfAA+ioA9 ddreS3---"7 KA30tO- RA, 51{+*wIty_Co cyo Lic# 6S;4Kgtik Phone#( 16�861^o40D,)(2,4 <br /> GIS Coordinates:X ,Y ,Township 4-N Range (21- Section <br /> WORK TO BE PERFORMED: <br /> ` NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION (choose type below) <br /> gSOIL BORING# S$--t p OVER-BORE. DIAMETER <br /> WELL# f'rtVl-g Q PRESSURE GROUT <br /> I]'Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WEkL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING XHOLLOW STEM DIA,OF BOREHOLE$:r a MULTIPLE CASINGS ra MULTI-LEVEL WELL CASING DIA: 2y <br /> EXTRACTION 11 AIR HAMMEWDRIVEN CASING THICKNESSSGS TYPE OF CASING: Q STEEL %PVC []OTHER: <br /> 11 VAPOR 13 MUD ROTARY. DEPTH OF GROUT SEAL t TREMIE TYPE TO BE USED: gAUGERS a HOSE <br /> 0 AIR SPARGE/OZONE p PUSH POINT(GP or CPT)GROUT SEAL PUMPED: V Yes 11 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> )KSOIL BORING p HAND AUGER GROUT SPECIFICATIONS AAA+ C-eve„+- <br /> a OTHER: n OTHER APPROX.BORING DEPTH_ Soy 1045 'BOLTED TRAFFIC BOX or 1]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED N o (if 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 Ordinances,Rules and Regulations,and all applicable California State haws. <br /> Signed x Tltle/Company er-+- Geo(o5 JtAJerMj-eonA( 3:1Nc- <br /> Print Name Q ri a n Ga r eJ Date <br /> DEPARTMENT USE ONLY y <br /> SITE MAP IN UNIT IV FILE,ADDRESS: j, j V � <br /> WORK PLAN DATED: <br /> Application Accepted By Date Issued <br /> Grout Inspection 8y Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> 50� Q ? SR# QQ <br /> 3 Sz <br /> C-57 WC -WAIVED.._ C-57 Letter of Authorization to sign permit Encroachment doc__,_ 9/30/02 <br />