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12/27/2002 14;34 20946e343 - - -FIFTH FLOOR_ 'PAGE---04 <br /> fi-- <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicatlon Is hereby made to San Joaquin County fora permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9.7115.3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location l 3 20 N• E DO�'f�Cl S Cross Street N_wnCity StdeA�, ZipS_ �� Assessor's <br /> Q yG/ GParcel#/Z✓1_ /�-� <br /> PROPERTY Omer c5 G� (Oil iiSAddress P.�)• 8V t!]6 <br /> 1 CityZp 9/,S Phone# <br /> a <br /> Cl Contractor Address 9.Jm /IJ�p•1,ye Sf. City .I Zip J,j Lic# Phone#91T:_3/i•,STiOU <br /> Censultantl Sub CntrAddressGZ&�/,$a.c rD,ycap(y�O;ty�r��LicYF phone# 5/r�•,ZZy-y�,Zy VVI <br /> GIS Coordinates:X ,Y ,Township— 1 <br /> P Range Section— <br /> WE LL <br /> ectionWELL/BORING(.CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') 11 DESTRUCTION(choose type below) <br /> p SOIL BORING# H OVER-BORE <br /> COMMENTS -tLW ELL# H W-% �o /'l 6^U -`Y Grout Specifications: 0 PRESSURE GROUT <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> '](MONITORING HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?II YES N0 WELLCASINGDIA: <br /> Q\EXTRACTION II AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING! 0 STEEL PVC.. p OTHER: <br /> ()VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: <br /> a AIR SPARGE Q AUGERS OSE <br /> I]PUSH POINT GROUT SEAL PUMPED: 1]/Y�es `)<I (NOTE: MAXIMU FREE-F 1IL DEPTH IS 30') <br /> [J SOIL BORING (]HAND AUGER GROUT SPECIFICATIONS:CO�i�.f <br /> Q OTHER: . n OTHER APPROX.BORING DEPTH <br /> - BOLTED TRAFFIC BOX or [I STOVE PIPE <br /> 'COMMENTS: CONDUCTOR CASING PROPOSED?_(if YES,list specifications here): <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. I <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinan es, Rules and Regulations, and all applicable California State Laws. . <br /> signed x 14 Title/Company // <br /> 'riot Name Data 2 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS; <br /> NORK PLAN DATED: <br /> \ppllmtion Accepted 8y �� Date Issued �(/� Area f <br /> Smut Inspection By Date Inspection I Date t[ <br /> )est action Inspection B Date 41-111 <br /> - <br /> i <br /> )OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# eery <br /> PE CODES FEE INFO AMOUNTREMITTED CHECK# REC' Y DATE PERMIT/SERVICE REQUEST C INVOICE f <br /> 2 <br /> dLjo qZm sRu 3 3 � <br /> -57 WC -WAIVER_ C-57 Letter of Authd tot sign permit_Encroachment doc� 1/25/02 <br />