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0913612004 10 45 2694683433 FIFTH FLOOR PAGE 02 <br /> I <br /> WELL PERMIT APPLICATION FURM SITE <br /> ISAN JOAQUIN COUNTY MITIGATION <br /> . ENVIRONMENTAL HEALTH DEPARTM5NT (EHD) UNIT IV <br /> I _ 304 E Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468.3449 <br /> NON REFUNDABLE PERMIT EXPIRES 1 YEAR ERR02MM DAT@ ISSUEL] <br /> Appiscaton is hereby/Wade to San Joaquin County for a permit to cons',uct and/or install the work described This appiication ss made m Compllano�with San <br /> Joaquin County Ldvoiopment Title,Chapter 9 1115 3 and the Standards of San Joaquin County Environmental Health Department <br /> oe Pa1%hbAssessors <br /> WELL Location X36 `^r� n`I- L-,t� fid, Cross Street IGw City�'rp C z]p 9—1-710& Parcel# ZZ3 J3 (� <br /> PROPEF2TY Owner -L-'i tr A �.[ Address P L1, �D X 14 City ba i ja& r)( Zip � PhQne# <br /> `T q4,; 313-5V00 <br /> 0 57 ConiractorrEC 1 - V Address 95� bWL. City/�ar'�`i�le. Zip- Lic# �Ph4nex <br /> Ro me 110 <br /> Consultant/Sub CntrSELCQ ._nir-er" � Address 'Oi 4Cr tr,e 4�� S CIty�6rda�s'i�Llc#b$tl`1qg Phone#jj A?6f- 400 <br /> to <br /> (`,IS Coord rates X Y ,Towns`irp_ _ $dt I'h, Range Becton <br /> I W01 TO BE PERFORMED <br /> NEW WELL 180RiNG CPT GEOPROBE,HYDROPtJNCH,HAND AUGER,OTHER') [�DESTI�UCTiON (choose type below) <br /> )L,901 1-BORING# __ 1p 3 OVER-SORE DIA <br /> McTER <br /> WELL# PRESSURE GROUT <br /> Q <br /> [I`Other GROUT 5PEOIFICTN <br /> A IOS <br /> ICOMMENTS <br /> I TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING HOLLOW STEM DIA OF BOREHOLE_ []MULTIPLE CASINGS I]MULTI-LEVEL WELL CASING DIA <br /> d EXTRACTION []AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING []S7EEL 0 PVC []OTHER <br /> #J VAPOR MUD ROTARY DEPTH OF GROUT SEALEAL O TF�PMIE TYPE TO BE USEE) U AUGERS WHOSE <br /> I AIR SPARGE/OZONE PUSH POINT(GP or GPT)GROUT SEAL PUMPED )ZYes ❑No (NOTE MAXIMUM FREE-FALL DEPTH IS 30) <br /> SOIL BORING 11 HAND AUGER GROUT SPECIFICATIONS �g <br /> CI OTHER_p OTHER __ APPROX BORING DEPTH is Ur a BOLTED TRAFFiC SOX or Q STOVE PIPE <br /> CONDUCTOR CASING,PROPOSED (If YES Iist speciflcatior's in comment sect on) <br /> COMMENTS <br /> MOTE, OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTION$ <br /> IL <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaq <br /> County Ordinances, Rules and Regulations,and all applicable Califurnia State Laws <br /> Signed x _1�-��"� __—_ _ TideiCompany <br /> Print Name {�f`.Ai\ Cir �� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV Fli.Ef <br /> ADDRESS.- _.._ _ ., <br /> WORK PLAN DATED. <br /> Da'e Issued �1�7� Area �'� <br /> Applloatran ACCepted Ey �� t- � <br /> I Sy t <br /> r w� Date Q Final Inspeotran By Date <br /> Grout Inspeat,on <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS <br /> IACCOUNTING ONLY AIL)# +FA(-,#jjjjjjj� PE CODES FEE INFO AmouNT REMIT(ED CHECK# C'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 2 _yj I rev oL� s # 011 <br /> WC____-WAIVER C-57 Leiter of Authorize#ion to sign perMIT EIncroachment doc 9/30/02 <br /> I <br />