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12/23/2005 11:50 2094 433 EHD PAGE 02 <br /> WELL PERMIT APPLICATION FORM 1-op Sj 1 E <br /> SAN JOAQUIN,COUNT`f MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT N <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3445 - <br /> 1 <br /> ON-REFUNDABLE PERMIT EXPIRE 1 YEAR FROM HATE ISSUF-D r` 7 <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 compiian Jl <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of Sa Joa uin County Environmental Health Department a Gov�.$ I <br /> L'3Za �f City Zip Parol#'–L—LL <br /> � �� Cross Street <br /> WELL Location GI ,9 �! S zu <br /> r o L=. 1�(F�c l•�ti r!v� City ,�Inc' / „Zi9 ?hone# <br /> PROPERTYOwnar '` Jb �„ dress- <br /> PROPERTY <br /> ress 4 q"C - <br /> Ct / 6Ss>E /6 � <br /> I�.J_��l;�Zj��C L?r�' Phe'• <br /> 0-67 Coni Y1�—�1�: Address <br /> Address City ' ;� Phone:# <br /> Consultant/Sub Cntr N a- �— <br /> GIS Coordinates: <br /> Township Range mon <br /> W R T PERFORMER' <br /> 0 NEW WELL I BORING (CPT,GEOPROBE,HYDROPUNCH,HAND AUGER OTHER') p Dl~0SOVER-SORE.TON D EL1'pe below---- <br /> "Di BORING# 0 PRESSURE GROUT <br /> j]WELL# GROUT SPECIFICATIONS <br /> p=Other S .313 <br /> COMMENTS: <br /> CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL INSTAL1l►TION TYP MULTI Pi CASINGS �J MULTI-Lc'�,'EL WELL CASING 0� <br /> MONITORING `�EiOLLOW STEM DIA.OF BOREHOLE�f Q <br /> (�` ;} TYPE OF CASING: 0 ST=-L 0 PVC 0 O7HER: <br /> EXTRACTION 0 AIR HAMMEFVDRIVEN CASING THICKNESS A,' TREMIE TYPE TO BE USED: UGE4S G ItiOScJP`Jc <br /> [j VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT Sa,*-PUMPED: 0 Yes p N NOTE: MAXIMUM FRE` �L DEPTH IS 34') <br /> * OIL BORING a HAND AUGER GROUT SPECIFICATIONS /` <br /> OTHER APPROX BORING DEPTH 11 BOLTED TRAFFIC BOX or a STOVE PIPE <br /> 0 OTHER:��� �' (if YES,list speoifleations in comment SectM) <br /> CONDUCTOR CASING PROPOSED. ( <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCT cE AGREEMENT <br /> FOR 1 O pFcN QR�OACHMENT PERMITS. <br /> 48 WORKING HOURS N <br /> I hereby certify that I have prepared this application and that the work will be done in accordance-1,S. <br /> w San Joaquin <br /> County Ordinan ,Rules an a ations, and all applicable California State Laws. ti / <br /> w/� Title/company �t'v�� ,7 Ei ;,�.. G`'- <br /> Signed x , f <' S' <br /> it, z o c.c�51�° Dale �trc �..�.. ZY 2c, <br /> Pont Name L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT N FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> Date Issued Arca <br /> Application Accepted By ti Date/ i 1 0�'� Fnal Inspection By/ /� O Date <br /> Grout Inspedon By <br /> pastructden In3oection BY Date <br /> COMMENTS I CONDITIONS: Ah 14 N2W M <br /> ACCOUNTING ONLY: Ali FAC# <br /> PE CODEs FEE INFO AMOUNT REMITTED CHECK# REC'D SY DATED 3� PERMIT <br /> IS I SERVICE REQUEST# INVOICE c r C 5 r' <br /> c�-�.ol �� 9J3D/02 <br /> C-57— WCi WAIVER_ C-57 Letter of Authorization tO Sign permit,Encroa&Ment dor— <br />