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10/17/2002 08:37 209468 FIFTH FLDOR • PAGE 05 <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 <br /> (209) 466-3449 <br /> NONREFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED <br /> Application is hereby made to San Josquln County for a Permit to construct and/or install the Work described. This application is made In comphar"with San <br /> OJoaquin County Development Title.Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> V�2��:w` � Assessors <br /> wiY ocauon (t Al1— I �0- Cross Street W1f 1 NJi City S iec.Lc-ins+ Zip ParceMf <br /> PROPERTYOwnerv�t/L4 41:: , � Address.S23Y &'LAtjr TA C A.Adnt.LwaL Zip PhoneN516 - 34q-�47,1- <br /> C-67Conhactor-V�FIJ tla'Ll :�__Addross l",o gcx `tILGty1-, (a- N ZiP`f- Yl Uax'1> OyPhoneitS(k-l77y <br /> - lrt <br /> Consultant/Sub Contractorhs P, C- +vjti Address141s�(77 C�yv pnaullrl_ Cily �nGTL Lich Phonetry�IL -42l -�cc <br /> GIS Coordinates:X ,Y .Township Range Section <br /> WORK TO Ba PERFORMED: <br /> D NEW WELL/BORING(CPT.GEOPROSE.HYDROPUNCH.HAND-AUGER,OTHER') 0 DESTRUCTION(choose type below) <br /> OIL BORING X d) D OVER-BORE <br /> D WELL a / D PRESSURE GROUT <br /> 'Other: Grout Spedfaztions; Nu.K 11L+.r�YT <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> []MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE 2 " MULTIPLE CASINGS?0 YES 00 WEAL CASING DIA:_ <br /> 0 EXTRACTION n AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: O STEEL 0 PVC D OTHER: <br /> 0 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED; D AUGERS D HOSE <br /> D'AIR SPARGE jtj�USH POINT GROUT SEAL PUMPED: 0 Yes "o (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> '-ROIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: Nye uCr.;+-s..rr- <br /> 0OTHER: C OTHER APPROX.BORING DEPTH-S-- 7-0 t n BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> ALL T I7 <br /> C HE UN IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Or i anCes,Rule nd Regulations and all applicable California State Laws. <br /> Signedint NX <br /> Print L <br /> DIEP1A(-RpTMENT USE ONLY /` <br /> SITE MAP IN UNIT IV FILE,ADDRESS:�---l0 `L-4 �A�M� ��(i�G-'r p� <br /> WORK PLAN DATED: 1 t71 Z <br /> Application A=pted By Data hexad 2� lvea- <br /> Grout Inspedon By D01940l Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTINGONLY: AID# cera <br /> FE CODES FEE INFO AMOUNT REMITTED CHECKC RECD BY I DATE PERMIT/SERVICE REQUEST0 INVOICG <br /> Id �l a s <br /> C-57_ WCC WAIVER C-57 Letter of Authorization to sirgt permit Encroachment dot` • 1/25/02 <br />