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03/27/2003 10: 57 20945834?- FIFTH =LOOK PATE 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 <br /> (209) 4W-3"9 <br /> Np*aI!FUNDAQLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County Tor a p6rmit to Construct and/or Install the work described. This application is rrede in compliance with San <br /> Joaquin County Development Title,ChdpWr 9-1115.3 and the Standards of San.lcagLin County Environmental Health Department. <br /> � Assessors <br /> F1 <br /> wL Location �� ! 1! /''fTCY _!i_Cross Street City zip q� Paro �/�O X10 <br /> El# f -1Z <br /> PROPERTY Owner /QS ��9a'N"s Address ,*-V 13a, r9a7 City �lf Zif.Y Phone# tZ2 / S'Z <br /> C-M Contractor Addrress�D /G _ /�T+'� z1p99ty/uc Phonwo _Z 77 9W­' <br /> Consultant r Sub cntr�r �-e F d Addres�Q37 {+fir-►•a'+ clty_tjg4!�eourix :�'A gy Phone# <br /> GIS Coordinates:X ,Y ToMmel-ip Range Section <br /> WORK TO BE PERFORMED: <br /> -'NEW WELL 1 BORINGS (CPT.GFO R08E,HYOROPUNCH,HAND-AUGER,OTHER*) p DESTRUCTION (chaoea type below) <br /> 0 SOIL BORING# 71—V p OVER-BORE. DIAMETER <br /> 0 WELL# a PRESSURE GROUT <br /> .Other GROUP SPECIFICATIONS��4 <br /> CONWENTS: d ea ,r'O�C 60 P/!j! S 7U �✓ <br /> TYPE OF WELL. INSTALLATION TYPE CONSTRUCTION 6PECIFICATIONS <br /> D MONITORING Q HOLLOW STEM DIA,OF BOREHOLE( VULnPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: <br /> d EXTRACTION Q AIR HAMMERiDRIVEN CASING THICKNESS TYPe OF CASING' (]STEEL O PVC Q OTHER <br /> D VAPOR Q MUD ROTARY DEPTH OF GROUT SRAL TREMIE TYPE TO SE USED: GAUGERS 0 HOSE <br /> p AIR SPARGE/OZONE p PUSH POINT(GP or GPT)GROUT SEAL PUMPED: p,Yes p No (NOTE: MAXIMUM FR�E.E.-FALL DEPTH IS 30') <br /> OIL BORING n HANC AUGER GROUT SPECIFICATIONS G la s S C- Ply/ <br /> (�OTHER. p OTHER• APPROX.BORING DEPTH a 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br /> CONDUCTOR CASING PROPOSED V YE&list speaficatk=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 eartify that 1 have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, Rules and Regul Ions,and all applicable California State Laws. <br /> TitlelCompany�/" 1' . GPO f�C�SC �Mi�/�'O-v�� Ta� <br /> Signed x / <br /> Print Nom• s• TC4 Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT rV FILE,ADDRESS: <br /> WORK PLAN DATED: J l ZOO <br /> Application Accepted BY <br /> Date Issued �/ 23/b Area <br /> Gmt kwooJon By Date Final Inspection Sy Date <br /> Destrodtlon Inspection By Dale <br /> COMMENTS I CONDfT10N3: <br /> 7"161FI <br /> LY: AID# PAG# <br /> CODESL I}IFd AMOUNT REMITTEt? CHECK O RCC'D EY DAT! PFJiM1T/SERVICE RECUESE* ftE] <br /> l d7 f /1 z�zz o S� U DO <br /> C-57_ WC=WAIVER— C-57 Letter of Authorization to sign permit_Encroochmerit doc_ 9/30/02 <br />