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02/09/2003 14:35 2094633 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM <br /> SITE <br /> FEB 2 2003 SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton_, CA., 95202 <br /> P[� •�I ISEF,VII.;`i (209) 468-3449 <br /> NON-REFUNDABLE PERMIT 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 compllance with San <br /> Joaquin County Development Tuttle,Chapter 9-1115,3 and the Standards of San Jo <br /> Jaquin County Envkonm//ental Health Department. <br /> Assess <br /> WELL Location Tho s AW1914111 Le Cross Street L-o City l TJ Zip Parcel#oreZ9i_Jp_3C <br /> �/ y y 1 i G ?Z eG./re <br /> PROPirRTYQwner T �i /ti3'✓ ARidressE/v8t�1 �F'e��7 "Clty� ziPhone# / <br /> C-$7 Contractoe Oc r'(�' Address,_m�O Z-,p Ltc# L6�7 Phone 067 37'1-:`,Jeo <br /> Consultant/Sub Cntr�. 6' J La Address,22,70 6ciie®y cityLi,# Phone# /l6 C7!' )0,30 <br /> GIS Coordinates:XY Township Range 'E' Section /6 <br /> WORK TO BE PERFORMED, <br /> O NEW WELL I BORING (CPT,GEOPROBE.HYDROPUNCH,HAND-AUGER,OTHER") Q DESTRUCTION (choose type below) <br /> I]SOIL BORING# Q OVER-BORE. DIAMETER <br /> j WELL# /n�.! ©PRESSURE GROUT <br /> II*Other ' GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> O MONITORING HOLLOW STEM DIA.OF BOREHOLE o MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA- <br /> 0 EXTRACTION Q AIR HAMMERIDRIVEN CASING THICKNESS Sch V D TYPE OP CASING: p STEEL iFPVG D OTHER: c <br /> flVAPOR MUp ROTARY DEPTH-OF GROUT SEAL S TREMIE TYPE TO BE U5Ei7: ,@ AUGERS p HOSE <br /> 0 AIR SPARGE!OZONE U PUSH POINT(GP or CPT)GROUT SEAL,PUMPED; 0 Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0SOIL 80RiNG HAND AUGER GROUT S?EGIFICATIGNS�C?�rl L�P✓lrzrf _ <br /> OTHER: 0 OTHER APPROX BORING DEPTH O A BOLTED TRAFFIC BOX cr STOVE PIPE <br /> CO D GT/QR CASING R/OP0 ED O (it YES,list specifications in comment section) <br /> 41 <br /> COMMENTS: P /f— 1 L° /0 <br /> NOTE: OFFSITE BORT GS REQUIRE ACCESS AGREEMENT OR ENC OACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Jaaquin: <br /> County di n s, Rul an Re tions, and all applicable California State laws. <br /> I <br /> aigned z Title/Company S <br /> X,/�_� <br /> print Name S:,:, <br /> DEPARTMENT USE ONLY:; <br /> 3ITF MAP IN UNIT IV FILE,ADDRESS: <br /> NORK PLAN DATED: ' <br /> Lpplication Accepted By Date IssueB1�0 Area <br /> 3rout Inspection By Date Final Inspection By Date <br /> ,testruction Inspection By Date <br /> :OMMENTS/CONDITIONS: awe A, S " <br /> ACCOUNTING ONLY: AID# FAC## <br /> PE CODES FEE INFO AMOUNT REIHfTTED CF#ECK# REC'D BY DATE PERMIT!SERVICE REQUEST>r INVO[CIE <br /> Sar' $ GSz3o (.J o SR# d o 3L9 d <br /> -57 WC -WAIVER__. . C-57 Letter of Authorization to sign perrhit .l=ncroachment doc 9/30/02 <br /> I . <br /> �y <br /> E <br />