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0-2/03,'2003 14:35 20941 .433 FIFTH FLboR PAGE 02 <br /> < _', .',' , ; <br /> WELL PERMIT APPLICATION FORM SITE' <br /> ��c< SAN JOAQUIN COUNTY <br /> MITIGATION <br /> FEB 2 A, 2003 ENVIRONMENTAL~ HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202. UNIT IV <br /> (209) 488.3449 <br /> NON-REFUNDABLE PERMIT EXPIRE5 IyIGAR FROM DATE ISSUED - <br /> Applicatlon is hsreby 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 /> t� i,�f� L [ / Assessors <br /> WELL Location f rr I1T� }, l it1/�o/ �rts Cross Street " City 1(K�K1 v1 Zip Parcel# <br /> PROPERTY Owner l/116, 'V4 G'P '+eS1�. Addresse �]X�A ��RC(lty�.i ziphone# <br /> C•57 Contractor (,l/t7L� t+//�c7C� !� !t" Address. �0^} eves! .JCI aDI -Cit �0 v•S Zip U.# JCC,7 Phonee# 7o7 73p7y-�30c <br /> Consultant 1 Sub Cntr. V/C C0! Address d�70 V 4 Jit civ (1/'0 i ^ -4 Lic# Phone#t��6 I/ -,2 <br /> GIS Coordinates:X 'Y Township 1�/ Range_ Section _e-)ii <br /> WORK TO BE PERFORMED: <br /> Q NEW WELL I BORING (CPT.GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER`) " Q DESTRUCTION (choose type below) <br /> Q SOIL BORING# Q OVER-BORE. DIAMETER <br /> WELL#J k/ W- Q PRESSURE GROUT <br /> *Other GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYFE CONSTRUCTION_SPECIFICATIONS �7 <br /> MONITORING HOLLOW STEM DIA.OF BOREHOLE-1,C Q MULTIPLE CASINGS Q MULTI-LEVEL WELL CASING DIA: C � <br /> a EXTRACTION DA.I I R HAMMER/DRIVEN CASING THICKNESS-5', a TYPE OF CASING: Q STEEL 10 PVC [I OTHER: <br /> 0 VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL - 30 TREMIE TYPE TO aE USED; .AUGERS Q HOSE <br /> p AIR SPARGE/OZONE (]PUSH POINT(GP or CPT)GROUT SEAL PUMPED: ®Yes No (NOTE:. IMUM FREE-FALL DEPTH IS 301 <br /> Q SOIL 80R!NG p HAND AUGER GROUT SPECIFICATIONS_ zy -/ C-ellyi? <br /> Q OTHER:_n OTHER APPROX-BORING DEPTH 1 IPBOLTED TRAFFIC BOX or I)STOVE PIPG 1Z <br /> / <br /> CONDUCTOR CASING PR PO ED �a (if YES list specifi/cation$in comment section) <br /> �dMhRENTS: ! jo 1--t. 'n" cJfl� LG/� /� .? / i le �O a <br /> NOTE: O FSITE SORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT ERMITS. � <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. t <br /> 1 <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ;ounty Ord" nc , Rule and Rego orfs, and all applicable California State Laws. <br /> Signed x Title/Company <br /> 'riot Name i4 ate /0 <br /> DEPARTMENT USE ONLY. <br /> ;ITE MAP IN UNfr IV FILE,ADDRESS: <br /> IIORK PLAN! DATED:_-1i3Z o,,, &� tt LbP 5W. <br /> pplication Accepted By Date Issueck Area <br /> rout Inspection ey Bate 20 IL Final Inspection By Date <br /> astruction Inspection By Date <br /> 3MMENTSICONDITIONS: - col LLoP 5 GUST 6 2. 4w' <br /> ACCOUNTING ONLY: AID# FAC# <br /> 'E CODES fEE INFO AMOUNT REMITTED CHECK# REC-D BY DATE PERMIIT I SERVICE REQUEST A! INVOICE <br /> 3fDI �l - 49 1;146-5 C SR#pp��-2-9C,<r <br /> -57 WC=WAIVER___ . C-57 Letter of Authorization to sign Permit - Encroachment doc 9/30/02 <br />