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07/19/2002 08:18 2094683433 FIFTH FLOOR rNuc <br /> WELL PERMIT APPLICATION FuRM SITE <br /> SAN JOAQUIN COUNTY DNVUI� f ,� <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> ��" _ � <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 NOV 1 3 2002 <br /> (209) 468.3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> _r f\ Fye s Assessors <br /> WELL Location -�� •%[ �':- SST _ Cross Street City �7G�SzVv Zlp 'i '`. Parcell I <br /> PROPERTY.Owne{ Po ' uF ��sk�xJ Address t;stx774.'City Zip��� Phone# 202 4t{ 1`"IQ <br /> C•57 Contractor trCNA�'��` s.�l Address �22D to.Vis. S; city ;_ .y0Zip`11.-_nGUc#3LfLi3y Phone# O 608 <br /> Consultant/Sub Contractor ddress t? << ity ,.t:_t.;t Lic# Phon 1.3-1?— <br /> GIS Coordinates:X Y ,Township Range Section <br /> WO TO BE PERFORMED: <br /> I EW WELL KGOR.IN CPT,GEOPROSE, YDP,OPUNCH AND-AUGER.OTHER`) p DESTRUCTION(choose type below) <br /> 0 SOIL BORING 0 OVER=BORE <br /> 8 WELL 1 p PRESSURE GROUT <br /> 'Other. Grout Specifications: <br /> COMMENTS: tR—Dr--) RIF <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> p MONITORING 8 HOLLOW STEM DIA.OF BOREHOLE i-5 ' MULTIPLE CASINGS?0 YES ANO WELL CASING DIA: <br /> EXTPACTION ll AIR HAMMER/DRIVEN CASING THICKNESS �,rt-) TYPE OF CASING: []STEEL D P'VC (]OTHER: <br /> M VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: 'p AUGERS RHOSE <br /> iAIR PARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes D No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> (tOIL BORING n HAND AUGER GROUT SPECIFICATIONS: <br /> n OTHER- f r6THER (kC"0--F—q96- APPROX.BORING DEPTH f 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> _ CONDUCTOR CASING PROPOSED?_ K)-e, (if YES,list specifications here). <br /> 'COMMENTS, �t�ti;nUG_Gfi CF- <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CAI_I-TNF I INIT IV INSPFI;TOR 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 Orrfina c , Ria ps and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company C4►w;cr,_ r c«.r/_rs- 1-1I`r <br /> Print Name '4 FtZ Kc E'er Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /1 <br /> Application Accepted Sy.0t� Date Issued �l/ /)?i Ares V�J�C13 <br /> Grout Inspection By �Dat OZ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY: AID# cer+h <br /> PE CODES FEE INFO AMOUNT REMfTTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> �� g ?3G' �'s�`� l �I r sly 0 3117 01 <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit Encroachment dao 1/25/02 <br />