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01/25/2002 17: 38 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 Yo1 <br /> (209) 468-3449 FILE <br /> NON-REFUNDABLE PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> ApplicaUan is hereby made to Sen 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 /> Assessor's <br /> WELL Location 44arrs e r) Rd Cross Street 0 I+ e City Tracy Zlp Parcel# <br /> PROPERTY Owner-60 l&rl Stat a -I)g vC l CJ Address 43aJa71Ci 5'e-zo]- Cit Wmriot- ceeK Zipgy5q(7 Phone#43�)477)9ZE) <br /> C-57 Contractor � iYaAQX Address 2 1 IO MA/rs PrV City!5on Leand(DZip Y1453- Lic# Phone#610 5697676 <br /> Consultant/Sub Contractor IT Co rP Address 40OS-Por t ChrrAgo Fl isdu.Cjty. nC rr'C1 Lic# Phone# 92.9 ZBFf Z/45 <br /> GIS Coordinates:X ,V ,Township Range Section <br /> WORK TO BE PERFORMED: <br /> ,]'NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') [I DESTRUCTION(choose type below) <br /> SOIL BORING# ^' -tU(A I g OVER-BORE <br /> 0 WELL# ii +'� D PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE Z MULTIPLE CASINGS? O YES D NO WELL CASING DIA:_ <br /> D EXTRACTION I]AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC []OTHER: <br /> 0 VAPOR D MUD ROTARY DEPTH OF GROUT SEAL� TREMIE TYPE TO BE USED: D AUGERS D HOSE <br /> D AIR SPARGE PUSH POINT GROUT SEAL PUMPED: D Yes []No (NOTE: M,1"l UM FREE-FALL DEPTH IS 30') <br /> #SOIL BORING HAND AUGER GROUT SPECIFICATIONS' <br /> D OTHER:_0 OTHER APPROX.BORING DEPTH_D BOLTED TRAFFIC BOX or D STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> -COMMENTS: 711 <br /> NOTE: O FSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADV/ NCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws...h <br /> Signedx �-e.. 1.�`c� Title/Company 1T 6 0 KT02A T-1 0 /U <br /> Print Name - 7TncL E t R,4 eb Date l 12610-2- <br /> DEPARTMENT <br /> ZB102DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, DRESS: " <br /> WORK PLAN DATED: / <br /> Application Accepted By Date Issued '� o U�� Area�U" <br /> Grout Inspection By Date Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# cera <br /> PE CODES FEEINFO AMOUNTREMITTED CHECK# RECD BY DTE PERMIT/SERVICE REQUEST# INVOICE <br /> 7, 2- 1 s S�1-0 <br /> C-57_ WC_WAIVER_ C-57 Letter of Authorization to sign ermit_Encroachment doc1/25/02 <br /> 01/25/02 FRI 16: 43 [TX/RX NO 98521 0 002 <br />