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12/09/2002 10 05 2094683433 FIFTH FLOOR PAGE 02 <br /> L U:/ Ir Tf WELL PERMIT APPLICATION FORM <br /> f SITE <br /> U SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) UNIT IV <br /> D 304 E Weber, Third Floor, Stockton, CA , 95202 <br /> (209) 468-3449 <br /> NON REFUNDABLE PERMIT EXPIRE§tl YEAR FROM DATE ISSUED <br /> Application IS hereby made to San Joaquin County for a permit to construct andlor 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 Joagwn County EnvironnIenlat Health Department <br /> WELL Location ZUqE. CrCity (, Assessors <br /> Cross kZIP ParccelM <br /> PROPERTY Owner 991Address�f Y= (r<j! �Crty—E1W '- ZrP9-g5VPhone9{ f0�(rTj}.s Iva <br /> C 57 Contractor '( Address e <br /> CdyC�{Zrp_MLic#_yf5MPhcne#jLtMA11-51 1D <br /> Consultant/Sub Cntr N f-Addres C, ficeFa L,ct1KG,5;a+Phoneu / <br /> i <br /> GIS Coordinates X Y Tovtcs rp Rana Section Se-AL { <br /> WORK TO BE PERF15RMED <br /> �i iEW WELL/BORING(CPT GEOPROBE HYDROPUNCH ND-AUGER OITTHtER• y$ Z�`�� 0 DESTRUCTION(choose type below) <br /> )CSOIL BORING# C f i a OVER BORE <br /> 'Other 0 VL'ELL# >�S 0 PRESSURE GROUT <br /> Grout Specifications Pj' Oa� <br /> COMMENTS 2QpC-k-_ <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 9 MOti170RING p HOLLOW STEM DIA OF BOREHOLE 2u MULTIPLE CAStNGS7 p MULTI-LEVEL')Q WELL CASING DIA F43-4 <br /> 0 EXTRACTION L]AIR HAMMEWDRIVEN CASING THICKNESS__,, TYPE OF CASING 0 STEEL OP <br /> Q VAPOR d MUD ROTARY DEPTH OF GROUT SEALmk-Lp____TREWETYPE TO BE USED ©HOSE <br /> [)AIR SPARGE!Ozone 0 PUSH POIN7 GROUT SEAL PUMPED G Yes 13 No (NOTE MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING 0 HAND AUGER GROUTSPEMCA71ONS <br /> O7nER O I HER C Pf APPROX BORING DEPTH O -10 <br /> Q 0 BOLTED TRAFFIC BOX or 0 STOV_c <br /> PIPE <br /> /CONDUCTOR CASING PROPOSED') (if YES Inst specrficat ons hhere) <br /> 'COMMENTS Q I 6Wi►ts. `sr �,t tE 04.1 (Oc, p� sGQ t� CP� Vo—f i T.-4 V <br /> 0-g _ <br /> TE: OFFSITE BORI GS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> CALL THE UNIT 1V INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify that I have prepared this application and that the work will be done to accordance with San Joaquin <br /> County Ordina , Rules and Regulations,and all applicable California State Laws <br /> S fined x ,T,tle1Company V n <br /> 5 d <br /> Print Name Date 0 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADDRESS 21-5 <br /> WORK PLAN DATED z <br /> AppNcatlon Accepted By Dave Issued 72-� ! AreaD6 <br /> Grout Inspection 9y Data Final Inspection By Date <br /> Destruction InSpection By Date <br /> COMMENTS 1 CONDITIONS <br /> LA.CCOUNTING ONLY AID# <br /> ODES jFEEINFO AMOUNT REMITTED CHECK M REC D HY DATE PERMIT!SERVICE REQUEST# INVOICEa P .� Feb 0 ". p32�o857� WWAIVER_ C-5T Leiter of Authorrzotlon to sign permit_j!!�'Encrcochment doc_ 8/29/02 <br />