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04/23/2004 14:27 2003433 FIFTH FLOOR. PAGE. 03 <br /> WELL PERMIT APPLICATION FORM LOP & . ITE <br /> SAN JOAQUIN COUNTY MITIGATION. <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT I1' <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR EBOM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This appumoon is made in compliana with San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards ofSan Jo utIn County Environmental Health Department <br /> gTA(�,�. 1+ ASSessor$ <br /> WELL Location :�b'J�. E.• IJE Cross Street �C.IhIJ City SToc+KTt)r-1 Zip CIFJ%15 Parcel# <br /> PROPERTY Own" fEN r- AddressL.o�5ori o=5-119 Gty M,4*^ Zlp 3i1"�Phoneu io15 •"oiJ Z2y <br /> Cnulo <br /> C-51 Contrachlr uAxA �R1�L-�NLrAddress:>��� < -+kEL C1f'�� Cityy iaE, gA Zipq'��`1LLir#�I-Fj10 Phone#�IKa- b'�45-WA <br /> 2b,1 A <br /> contil t/sub Cntr�R.E`r' OM✓ (Zo�MCw':'�LAdtlress �aFAVL-c,•t=, Av6_ aty fiE Cl+ LIcnCC-C�15oo phone#ol�� <br /> GIS Coordinates:X ,Y Township T 1� Range L 15 Section <br /> WORK TO BE PERFORMED: <br /> D NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') D DEDSOTRUR TIOEN _DIAMETER ETe t a bel Iw) <br /> �SOILSORING# l'I 0PRESSURE GROUT <br /> D WELL# GROUT SPECIFICATIONS <br /> D*Other <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �. <br /> D MONITORING XHOU.OW STEM DIA.OF BOREHOLE O MULTIPLE CASINGS []MULTI-LEVEL WELL CASING C IA: N A <br /> D EXTRACTION D AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEALTREMIE TYPE TO BE USED: D AUGERS [ HOSE/PVC <br /> D AIR SPARGE1 OZONE D PUSH POINT(GP or CPT)GROUT SEAL PUMPED: L R Yes D No (NOTE: MAXIMUM FREE-FALL DEPT H IS 30') <br /> 'SOIL BORING D HAND AUGER GROUT SPECIFICA71ON <br /> D DTHER: d OTHER APPROX.BORING DEPTH LTO' D BOLTED TRAFFIC BOX or D STOV:PIPE <br /> CONDUCTOR CASING PROPOSED Of YES,list spedflcadons in comm Int 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 Jo aquin <br /> County Ordinan , Rules and Regulations,and all applicable California State Laws. <br /> Signed z _TtialCompany <br /> Print Nae— �(ZI V C�rT Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 5/A- ra <br /> WORK PLAN DATED:. <br /> Application Accepted By Date Issued <br /> Grout Inspection By 47�""'�-- <br /> Date 20 D y Final Inspection By Date ' <br /> Destruction Inspection By Date ENUIRONME[JT F'.'.F LI H <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES E INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT I SE;�c;EQUEST# INosD , <br /> IC-57_ WC_WAIVER C-57 Letter of Authorization to Sign permit_Encroachment doc,,_. 9/30/02 <br />