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02/26/2003 16:39 2094683433 FIFTH FLOOR PAGE 04 <br /> JFP <br /> Qv <br /> WELL PERMIT APPLICATION FORM <br /> SITE j <br /> FEB. 2 8 OHM SAN JOAQUIN COUNTY MITIGATION <br /> ETIROMIl I O, HEENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> hv11T SERV Ck— 304 E. Weber, Third Floor, Stockton, CA-, 95202 <br /> (209) 468-3449 ' <br /> �iNONAUUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Applicaden.e hereby matle b San Joaquin County for a Permit to eoruburs and/or Install the <br /> Joaquin Ccurlfy Development Title,Chapter @-1115.3 and dre Standards of San Joaquin County Environmental work eeauh Departmelice"On is nt- <br /> WELL <br /> In compliance with San ; <br /> WELL Location 0 E. + ,` Cross Street R PaeSsor i <br /> //�� (r`,�n, nn,�, Dityz; QST-, <br /> PROPERTY Owner�Y(1 lfYs� `.Zmvy"'Address T.(1 . <br /> • ^ �"r� ,1 <<Clb.- .�ZiP�a,�Grhane# — <br /> 057 Contractor ,� '�Address_ Ot`� ��Q. t;iry � <br /> Consultant/Sub Cntr 1�TC)n c,p, Address — <br /> --L # Phone# <br /> SGewLe o5ock `466n <br /> GIS Coortlinates:X ,Y', ,Township 't ti..,��L BRange___&Iit,Y(- SaetionS�_ <br /> WORK TO BEP Rr�'R ED: , <br /> jkNEW WEORING CPT,GEOPROBE'.HYDROPUNC ,HAND-AUGER THER-) D DESTRUCTION(choose type below) <br /> ,7W ..IN <br /> LL# a OVER-BORE <br /> -Othar" Grout Specifications, <br /> PRESSURE GROUT <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCT CIFlCATIO S f <br /> D MONITORING D HOLLOW STEM DIA.OF BOREHOLE N MULTIPLE CASINGS?DYES 1000 WELL CASING DIA: <br /> D EXTRACTION n AIR HAMMER/ORIVEN CASING THICKNESS—MIA—TYPE OF ASIING: D STEEL D PVC D OTHER: <br /> D VAPOR D MUD ROTARY DEPTH OF GROUT SEAL" utIE7ypE TO BE USED: D AUGERS HOSE I <br /> D AIR SPARGE D PUSH POINT GROUT SEAL PUMPED: D Yves ,)�Io (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> )SOIL BORING HAND AUGER GROUT SPECIFICATIONS: QO`C W O(N(�O��C Pt A MU S 30') <br /> 0 OTHER: D OTHER APPROX.BORING DEPTH r—(OI VYA!i D BOLTED TRAFFIC BOX a D STOVE PIPE I <br /> CONDUCT CASING PROPOSED7 _(if YES,fist specifiratlons here): 4 <br /> 'COMMENTS:_�(�v..� L2-..c.;.//� 14A I 'To <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT 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 Ordinances,Rule and Regulations, and all applicable California State Laws. •EA <br /> VApr _ <br /> >igned Title/CompanY�2s cc��i�i D, / ,yQ,y,�G(✓ tom_ ` <br /> 'rint Name Date Qt-W'In lr4 ���� <br /> ' DEPARTMENT USE ONLY 1 <br /> 31TE MAP IN UNIT IV FILE,ADDRESS."' S- /`eIleI, �G_• !N Ila <br /> NORK PLAN DATED:, _7 _0-,3 _ <br /> application Accepted By Date Issued .3,3 J 3 Ama_Y <br /> trout Inspection By Date /f Flna1 Inspection By Date <br /> lestruction InspeWon By Date <br /> :OMMENTS/COND,TIGNS: M� L✓ <br /> ACCOUNTING ONLY: AID# <br /> eerx ` <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# RECID BY DATE PERMIT/SERVICE REQUEST 19 INVOICE r <br /> qR# 3a �- <br /> -57_ WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 1/25/02 <br /> t <br />