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12/27/2002 14:34 2094683, FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JQAQUIN COUNTY MITIGATION <br /> 11f <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 4683449 <br /> NO14-REFUNDABLE PEAMIY 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 Side,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> 7� Assessor's <br /> WELL Locatlon23��Ct a& �iiAe.Rd. Gross Streat City zip tS37ii Parcel#21'1-Ogg-l* <br /> PROPERTY Owner, Sal ej10+1 fl 615 Address F 0- � to I r City. Zip q/?p Phone# <br /> C-57 ContractorAddress 9S city zip,��',S3 Uc*jk0/W Phone#_ZL-313-Saco <br /> Consultant l Sub Cntr Rig M Address Phone# 51 <br /> GIS Coordinates:X 'Y_ Township Range Section <br /> WORK TO BE KFORMED_ <br /> NEIN WELL)BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER;OTHER-) DESTRUCTION(choose type below) <br /> 11 SOIL BORING# 11 OVER-BORE <br /> VYELL#�[k-1 0 0 PRESSURE GROUT <br /> *OtherImo`` Grout Specifications, ,. - ..� <br /> COMMENTS <br /> TYPE OF WELL. INST,AL[_X ON TYPE CQaISTRUCTION SPECIFICATIONS f <br /> MONITORING 'HOLLOW STEM DIA-OF BOREHOLE_MULTIPLE CASkNGS?a YES ANO WELL CASING WA:� ' <br /> ©EXTRACTION []AIR HAMMERIDRIVEN CASING THICKNESS dAajak TYPE OF CASING: O STEEL APVC []OTHER: <br /> a VAPOR a MUD ROTARY DEPTH OF GROUT SEAL 0'-60 ' _TREMIE;TYPE TO BE USED: flAUGERS HOSE <br /> Q AIR SPARGE Q PUSH POINT GROUT SEAL PUMPED: p Yeses XNo (NOTE: MAXIMUM FREE-FALLl DEPTH IS 30') <br /> a SOIL BORING p HAND AUGER GROUT SPECIFICATIONS: 6reJ Q �� .Brrl".aal�6► S &4� <br /> 11 OTHER: []OTHER APPROX.BORING DEPTH .23 MOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? dO (if YES,fist specifications here): <br /> -COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 1V INSPECTOR 48 WORKING HOURS 1N,ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Orr dinances, Rules and Regulations, and all applicable Califomia State Laws. <br /> 3ign8d x TitlelCompany f <br /> fink Name Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> MORK PLAN DATED' <br /> tppllration Accepted By Date Issued. j Z Area <br /> "grout Inspection By Ont AAA izv anal Inspegtion By Date <br /> )estruction inspection Date <br /> :OMMENTS I CONDITIONS: <br /> ACCOUNTING ONLY: AID# etar* <br /> PE CODES FEE INFO AMOUNT REMrrTED CHECK# RE CID BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> SRS I Z3 G <br /> "-57 WC -WAIVER C-57 Letter of Autho Zati sign permit Encroachment dot 1/25/02 <br />