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04/25/2@03 13:33 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT HEALTH <br /> Application Is hereby made to San Joaquin Counl:y for a permit to construct and/or install the work described. This application is mune Rp5L"QiB6an <br /> Joaquin County Development rids,Chapter 9-1115-3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location 420 W- Ya lP_V IYk, L-A '_�r_ Assessors <br /> Cross Street 1IST��I t hS City LDd-i Zip�Parcel#P <br /> Me(ir�ol� �Ybera.. <br /> PROPERTY Owner Are Sz.,ders dress 2S zo City 'Dv-,v i s zlp 51'01 b Phone# <br /> C-57 Cont'a or �t(l i Address 950, BOW,& Clay�lzw�we Zip Lid# IbSPhone# 975--313--5Sao <br /> Consultant ISub Cntr C2LWt6V12'- Address Z-70 City SaY1orM2LLic# Phone# _101 -935-4850 <br /> GIS Coordinates:X 'y ,Township Range Section <br /> WORK TO BE PERFORMED; <br /> 0 NEW WELL f BORING (CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER-) DESTRUCTION (choose type el ) <br /> a SOIL 80R1N #- _ VER-SORE.-DIAMETER--- � <br /> a WELL# . 0 PRESSURE GROUT <br /> ©'other <br /> COMMENTS: GROUT SPECIFICATIONS <br /> E)X OF WELL INSTALLAYION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0,00NITORING a HOLLOW STEM DIA-OF BOREHOLE a MULTIPLE CASINGS a MULTI-LEVEL WELL CASING DIA.- <br /> 0 <br /> IA:0 EXTRACTION n AIR HAMMER/DRIVEN CASINGTHICKNESS TYPE OF CASING: []STEEL a PVC ]]OTHER* <br /> VWVAPOR (3) a MUD ROTARY DEPTH OF GROUT SEAT_ TREMIE TYPE TO BE USED: a AUGERS a HOSE <br /> n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: a Yes []No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> I]SOIL BORING a HAND AUGER GROUT SPECIFICATIONS <br /> 0 OTHER:_ H OTHER APPROX.BORING DEPTH <br /> a BOLTED TRAFFIC BOX or []STOVE PIPE <br /> CONDUCTOR CASING PROPOSED (f YES,list Specifications in comment section) <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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. <br /> Signed z (213191— Title/Company �P_G� Go�oQ I�� C2 wa�rr2�_ vj rb nrytec� <br /> Print Name �.�� c01 Date 4 - 11 - 03 <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> APPIICdtlon Accepted BYJAk, Data Tssued b Area 7 �' <br /> Grout Inspection Sy Fate Final Inspection ByDate f <br /> Destructlon Inspection By Date <br /> COMMENTS!CONDRIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOFCE <br /> 3Sn� bn 60 �-Saz {�/c �- a3 SR# 03 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sigh pertnit Encroachment doc 9/30/02 <br />