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04/24/2003 10:37 209468? FIFTH FLOORF1�P U Y <br /> E ab <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) 46$-3449 �5 C <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P 6' A. <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work dascrlbed. This application is made In romAp lann^ae wl h 5 <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Envlronmontal Health Departmant- - �� W <br /> M a 6C 1 J0g,2 h j n� /fir, Crass Street Y h,1. y c 7Rr9,/Y � p;roe4w- o-opo r 3 <br /> WELL.Location fly p <br /> PROPERTX 1797 7ris,1-lt K roc eao�menja IF 5"6'15 <br /> owner f QrC cls 6/"Vr IP Address S{f. C d U City. 2ip Phone# 4/ 77 2 0-dL o 0 <br /> r26 Vcd ocr,.,% S' ren,%✓ Sf2cL a2-,v Ss -e�,s \ <br /> 7J C-67Contractor:I C94 Address1S4 teav, City Zip Liatx Pho <br /> nwleonrn t C S7 <br /> Consultant/Sub Cntr.Cvn1rol Kceia- f Address3�ll, rwJn PFIMC CITy�S LO PhOnel(f74 G62 -���� ��sy7oj <br /> GIs Coordinates:X Y Township Range__— Section <br /> WORK TO BE PERFORMED, <br /> NEW WELL!BORING (CPT,nEOPF20B>=,HYDROPUNCH,HAND-AUGER,OTHER') D DESTRUCTION (choose type botow) <br /> SOIL BORING# 0 OVER-BORE.ei�WE t/ 0 PRESSURE GROUT <br /> •pth�Ti GROUT SPECIFICATIONS <br /> COMME 5: 0 <br /> TYPE OF WELL IN$TAt<1�T10N TY $ CO ST QCTION SPECIFICATIONS <br /> D MONITORING 11 HOLLOW STEM DIA.OF BOREHOLE 0 MULTIPLE CASINGS D MULTI-LEVEL WELL CASING DIA: <br /> D EXTRACTION p AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: D STEEL D PVC D OTHER- <br /> D VAPOR I7 MUD ROTARY DEPTH OF GRouT SEAL. TREMIE TYPE TO BE USED; 0 AUGERS 0 HOSE <br /> D AIR SPARGE!OZONEPUSH POINT(GP or CPT)GROUT SEAL PUMPED: D Yes 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> SOIL BORING HAND AUGER GROUT SPECIFICATIONS �ennQnt �rc.w+te <br /> OTHER,-_0 OTHER APPROX.BORING DEPTH , D BOLTED TRAFFIC BOX or D S70VE PIPE <br /> CONDUCTOR CASING PROPOSED (if 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 Califomia State Laws. <br /> ,/ — C>uf/c �i-� r A4sis /«J <br /> Signed x ��-��.��� TRIaJCompany �Pa �c'ff f ja - <br /> Print Name UO J/�5������ Date y ?� e 3 <br /> DEPARTMENT USE ONLY '� / <br /> SITE MAP IN UNIT N FILE,ADDRESS. �"�Q C' <br /> ,I <br /> WORK PLAN DATED' Dela lbsued �+K <br /> Application Accepleq By .` ` Are@ <br /> � <br /> Grout Inspection By Date Final Inspection By <br /> Destruction Inspection By Date <br /> COMWENTS 1 CONDITIONS: <br /> ACCOUNTING ONLY' AID4 FAC# <br /> PE CODES FI;E INFO AMOUNT REMITTED CHI=CK# REC'D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 7n XV ;a .5 5-1-o SR# Sd <br /> C-57 WC=WAIVER C-57 Letter of Authorization to sign permit,_Encroachment doc_ 9/30/02 <br />