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12/15/2005 08: 48 2094683 ' EHD PAGE 02 <br /> WELL PERMIT APPLICATION FORMECJEr SITE <br /> SAN JOAQUIN.000NTY u944TION. <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHDYEB 2 3 200YNIT IV <br /> -' 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 EfJVIP,0[Vr0ENT HEALTH <br /> PERMIT/SERVICES <br /> NON-REFUNDABLE PERMrr EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115,3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 5,56S my' .,)arvr Cross Street City-�lac cKTtsrsl Zip 1-57-Za­ Parcel# f QQ Qty 4 <br /> PROPERTY Owner WALE-86 Address ity.`1 Zip`1.l" Phone#i // <br /> C-67 Contractor W/Ji Address©fjy1,( ;.s Clty tit" iA ZipfyJZ Lic.#7i Phone# 7�'7"-3ZN- 'z30e <br /> Consultant/Sub Cntr Address 6•�SL),�jy2� ty-5 '�CJ Lic# Phone#`f�� `1Z 1-�/ �� <br /> GIS Coordinates:X Y ,Township Range Seoflon <br /> WORK TO BE PERFORMED: <br /> n NEW WELL/BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER.OTHER-) D SIRUCTION (choose type below) <br /> Q SOIL BORING# ER-BORE. DIAMETER /t., <br /> WELL# p PRESSURE GROUT <br /> Q"Otherl GROUT SPECIFICATIONS <br /> COMMENTS: AlLSI -12- e,%d 1­4 10 DZ7:s '>zL'C 7 .Te-TI <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING Q HOLLOW STEM DIA_OF BOREHOLE [I MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> Q EXTRACTION Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: Q STEEL []PVC n OTHER: <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: Q AUGERS Q HOSEIPVC <br /> n AIR SPARGEI OZONE n PUSH POINT(GP or CPT)GROUT SEAL PUMPED: d Yes Q No (NOTE: MAXIMUM FREE FALL DEPTH IS 301) <br /> Q SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS <br /> Q OTHER: 0 OTHER APPROX_BORING DEPTH n BOLTED TRAFFIC BOX or Q STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (if YES,list specifications in comment section) <br /> COMMRNTS: u i7 GST 2l t T-re l'i <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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 Ordinances, Rules and Re , lations, and all applicable California State Laws. <br /> f I <br /> Signed x �.� Title/Company L 7 /`(4 <br /> Print Name <br /> 13 rze-rr Date /I DEPARTMENT USE USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: o �U� -t-t- I v ���2i.� Q C t3 <br /> WORK PLAN DATED: <br /> Application Accepted By %C v�-ir e� Date Issued 2J2 7 E Area. <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection ByDate P,5704,-, — <br /> COMMENTS/CONDITIONS. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> ��,o I C21) ��.00 1��� f�2— 'H2-1 'o� SR# G� �7 y3 <br /> C-57 WC -WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />