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05/05/2003 14:49 2094683a?3 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH,00Stockton CA.T9520Z <br /> (209 (EHD) 458-3449 <br /> 304 E.Weber, Third Floor, <br /> MAY 0 8 [003 <br /> NON-REFUNDABLE PERMIT EXPIRES I YF-AR FRO DATE tSSUED de in <br /> the work described. <br /> A tication is hereby made to San Joaquin County for 8 d cation is Me <br /> I Bhandards of San Joaqccmsttuctandlor uinl County Environmental HeatthThis ilDepartme Department.Assessor's with San <br /> PP 161 030 01 <br /> Joaquin County Development Title,Chapter 9-kr_ Clty ST G G-KTOtq ZIp q 5s2D 3 Parcel# <br /> ACROS3 <br /> Cross Street <br /> WELL Location 3s0 n- R1`(T Phone#Jog C 4 9 4189 <br /> PROPERTY Owner P R 1 -O o ddress�ZO I W WASI-t1N ffT City CA <br /> ZiP—�-- % 34`(2 O o <br /> 3 $3 c T rl Cityacru�'�Nb Tap�.6�Liot't 6�55G Phone�_._.�.-- <br /> C-57 Contractor C� RAT10� ,Addra�- -- Phone#�IG �9� 3E;QE3 <br /> Address_300 1 }I S S o City GAk lN]e(2—Lio# <br /> Consultant/Sub Contractor — Section, <br /> GIS Coordinates:X,_ <br /> Y Township Range <br /> WORK TO BE PERF"MED: j]DESTRUCTION(choose type below) <br /> JNF_W` (ELL!BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) Q OVER-BORE <br /> Q SOIL BORING# r I Uu I� g L� PRESSURE GROUT <br /> ;kWELL# =14+x—�-�---r�ut Specifications: <br /> 'Other; <br /> COMMENTS: <br /> INSTALLATIONTYPE CON 5-TRUCTIONSPECIFICATIONS <br /> TYPE�F W LL DIA.OF BOREHOLE"_MULTIPLE CASINGS?0 YES 'ANO WELL CASING DIA: <br /> IrMONITORING gHOLLOW STEM <br /> TYPE OF CASING: ($STEEL V PVC 13 OTHER: <br /> Q EXTRACTION Q AIR HAMMERlDRIVEN CASING THICKNESS„ TREMIE TYPE TO BE USED: 0 AUGERS lKHOSE <br /> U VAPOR n MUD ROTARY DEPTH OF GROUT SEAL <br /> ,GE p PUSH POINT GROUT SEAL PUMPED; $Yes p No (NOTE: MAXIMUM FREE-FALL.DEPTH IS 30') <br /> 0 AIR SPA <br /> GROUT SPECIFICATIONS: <br /> (l SOIL BORING n HAND AUGER OTHER: 8 OTHER APPROX_BORING DEPTH UP o O 'BOLTED TRAFFIC BOX or (KSTOVE PIPE <br /> CONDUCTOR CASING PROPOSED? KO (if YES,list specifications here); <br /> Gkgi <br /> -rQfuIMENTS• D <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT P PERMITS. <br /> MI . <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL 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 Ordinances, Ru es a d Regulations,and all applicable California State Laws. <br /> TitlelCompany D G <br /> Signed x Date <br /> Print Name G <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Area--'�� <br /> Application Accepted ey Date_ <br /> Date Final Inspection By <br /> Grout Inspection By <br /> Destruction Inspection BY Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'0 BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> S # <br /> ermit Encroachment doc <br /> C-57 WC -WAIVER C-57 Letter of Authorization to Sign p <br /> 1/25/ <br />