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03/27/2003 10:57 209461 ,;- 33 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SIYm <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT Id <br /> 304 E. !!Veber, Tftlyd Floor, Stockton, CA., 95202 <br /> (209) 4U-3449 <br /> LE PE PI YEAR FROM PATE ISSUED <br /> Applicaton Is hereby made to San Joaquin County for a permit to construct ondlor Inmll ft work described. This appllcatlon is mede In compliance v t}t San <br /> Jwwln County Development Title,Chats,9-9115.3 and the Standards of San Joaquin County Environmental Hesith Department. <br /> 4.WELL Location_� � �. JON o O Cross Street q��}�• Assessors <br /> //Gil/+flCity Sr( zipr�_ParcO./7 "/Z � y <br /> PROPERTY Owner kf o� STtx cc' Address ���� _City ST�j Zip 4o20/Phone#_rf 9 <br /> C-67 Contractor /1 iry Address)V&k cn ''o �p -y <br /> Consuttortt l Sub cntrr:o�l ori ��✓ AddressQZ j37G�,. cl°ty�l�u�Phor, hZ�G��3 <br /> GIS Caordinatea:X 'y Township Range Section <br /> WORK TO BE PERFORMED: <br /> ANEW WELL_/BORING (CPT,GEOPRO8E,MYOROPONCH,HAND-AUGER,OTHER•) Q DESTRUCTION (chooee type below) <br /> Q SOIL BORING# 0 OVER-BORE. DIAMETER <br /> ,,KNELL# 8" r/q 75r p PRESSURE GROUT <br /> a'Other I GROUT SPECIFICATIONS <br /> COMMENTS: tw <br /> TYPE OF WF11 IN TYPE CONSTRUCTION SPECIFICATIONS r �� <br /> Q MONITORING )�iOLLOW STEM DIA.OF BOREHOLEZ Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: y <br /> Q EXTRACTION Q AIR HAMMISR)DRIVEN CASING THICKNE 4 O TYPE OF CASING: p STEEL PVC Q OTHER <br /> XIAPOR p'MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS a HOSE <br /> FAIR SPARGE/OZONE Q PUSH POINT(GP or CPT)GROUT SEAL PUMPED: Q Yes Q No (NOTE: MAXIMUM FREE•-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HANG AUGER GROUT SPECIFICATIONS <br /> a OTHER: 0 OTHER APPROX,BORING DEPTH- St% MOLTED TRAFFIC BOX or Q STOVE PIPE <br /> ONDUCTOR CASING PROPOSED G YE3.list specificatk=in comment sec don) <br /> 0010AENTS: e c � air <br /> NOTE: OFFSITE BO GS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> I hereby certify that l have preparod this application and that the work will be dolls in aCCordrance with Sen Joaquin <br /> County Ordi noes, Rules and Regula ons,and all applicable California State Laws <br /> Signed x TitidCompany_(O''t SII1T 'f <br /> Print Name ✓'G� pate <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT rV FILE,ADDRESS: P Il 1P 1l 'w I <br /> WORK PLAN DATED/: <br /> Application Accepted B ( Date issued p MAR 2 5 200W14 <br /> Grout Nbpoctiort By Date Firtal inapeetlon ey n � ?Ptg <br /> Destruction Inopogcn By Date CfZ c) <br /> COMMENTS 1 CONDITIONS: Q1T4il� CII <br /> ACCOUNTING ONLY: AIBP PAC# <br /> PE CODES F,08 INFO AMOUNT REMITTED CHECK* RECD BY I DATE PERMIT I SERVICE REQUEST C IN <br /> es q lJ p SR# �p 7 <br /> C-57 WC_,_,;WA1VEI__ C-57 Latter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />