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07/19/2002 08:18 2094683433 FIFTH FLuurc -` <br /> WELL PERMIT APPLICATION FuRM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) 70v <br /> r <br /> 7 <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 -' ' `J <br /> (209) 468-3449 NOV 1 3 2002 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Cnl � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This a plica pfl"r�lwith San <br /> Joaquin County Development Title,Chapter 9.1115.3 and the Standards of San Joaquin County Environmental Health Depa e�f��T/CCp,1,ICEs �I <br /> WELL Location `�C rv'�V�C t�t�ti�� Cross Street City �f'�w~ n� Zip - ���F•• Paasrcell#b0� 1(A-030••-a ki <br /> PROPERTY Owner ce\ tys'-.� Address �1 ' �N+'� l/��y City - Zip P h o n e# Ick"fig-X4-7- <br /> C-57 <br /> 4-2C-57 Contractor F=:c�r•, .rt =.c ��'�-Address�='� �V E�� � City,;.�.,�7 2ip��"1l�Lic# Phone# <br /> �' ��3-3Cco <br /> Consultant/Sub Contractor L �CXzPnn9T+''U Address-� '� �T l x�'rE 'JCityy =Lic# Phone# 1 <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BEP ORM D: <br /> NEW WELL BORIN C GEOPRO HYDROPUNCH,HAND-AUGER.OTHER) p DESTRUCTION(choose type below) <br /> ING# n OVERBORE <br /> f1`NELL#_ Q PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: N-r.lrat_; Gr7D-5 <br /> TYPE OF WELL fNSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> Q MONITO^ING 0 HOLLOW STEM DIA.OF BOREHOLE 1 MULTIPLE CASINGS?0 YES ONO WELL CASING DIA: Krrj <br /> n EXTPACTION n AIR HAMMER/DRIVEN CASING THICKNESS �ty� TYPE OF CASING: p STEEL n PVC Q OTHER: <br /> flVAPOR (I MUO ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: .o AUGERS ;WOSE <br /> n AI SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL PORING n HAND AUGER GROUT SPECIFICATIONS: x>,-, <br /> n OTHER: HER Gcc% f'kc f-� APPROX.BORING DEPTH 7� a BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> <— CONDUCTOR CASING PROPOSED? 110 (if YES,list speaficatlons here): <br /> 'COMMENTS. <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> IrALL THF I INIT IV INSPFGTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orr ja cecuses and Regulations, and all applicable California State Laws. <br /> Signed n - Title/Company `++��cF -ar,crY�.1 V�5 <br /> Print Name �rR�f�S:►•� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Application Accepted By � Date issued/d/ <br /> Grout Inspecticn By Dace �, T" �L Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDMIONS: <br /> ACCOUNTING ONLY: AID# rens <br /> PE CODES FEE INFO AMOUNT REMrTTED CHECK# RECD BY DATE PERMIT!SERVICE REQUEST# INVOICE <br /> a-llof 3-Sb W� 1 / Zc SRlt Ob g0$ <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 1/25/02 <br />