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09/13/2004 12: 43 209468316 FIFTH FLOOR • PAGE 02 <br /> WELL PERMIT APPLICATION FORM LOP & SITE <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT(EHD) MITIGATION. <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin Countyfor a perndt to construct and/or Install the work desnribed. This a IlcatiOn i5 made In cont liance <br /> Joaquin County Development Tide,Chapter&9115.3 and the Standards of San Joaquin county Environmental Health Department P withSan <br /> WELL Location Db1J C-,76 g. e,/Qo g o a9( cross street f-4GY In h j2ol cl Assessors <br /> ty zip q S 330 Parcel# <br /> PROPERTYOwner D1-,41DDJC—$kq.vn- Address­g5o f4nl-l� Rd City L-ct �o zip 330 Phone#.�op-834-4174' <br /> C-57 Contractor r -1 , tvltPTe., %" <br /> dress o City nez Zip-a!55.3LIC#4 51(,S Phone#X15 -313'S MO <br /> ConsultantSes-Gntr �Pnror� Address a8'lOCra „Y,,,AgySiDr. acrav,�tntoO <br /> GIs Coordinates:X ,Y <br /> Swi 30 — Phone4/9 jj 6 4 3000 <br /> Townsh]P Range <br /> Section <br /> WOR (iE PERFORMED- <br /> EW WEL41 BORING (CPT,GEOPROBE,HYDROPUNGH,HAND-AUGER,OTHER-) p DESTRUCTION rl Dose <br /> SOiC BORING# ( type below) <br /> GIWELL#-NtrJ452 MW4114 --l.,�ozmc.�(4,,.,etts� 9OVER-BORE, DIAMETER <br /> 11*Other 0 PRESSURE GROUT <br /> COMMENTS: GROUT SPECIFICATIONS <br /> TYPE O WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> ONITORING 0 HOLLOW STEM DIA,OF BOREHOLE 10" 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: 9 `r <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNES$_50�- FO TYPE OF CASING: N STEEL <br /> 0 VAPOR &MUD ROTARY DEPTH OF GROUT SEAL/�/ 90 vctr D OTHER: <br /> tc5 REMIE TYPE TO BE USE UGERS OS <br /> 0 AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT BE PUMPED: &Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS.30') <br /> G SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Pe r}1 or t1__C�p� (-$Z usl �s) L <br /> Q OTHER: n OTHER APPROX.BORING DEPTH_ 0 BOLTED TRAFFIC BOX or <br /> ty-a i OVE PIPE <br /> COMMENTS: CONDUCTOR CASING PROPOSED n N Cd YES,list specifications in comment section) <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE REQUIRED FOR 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, Rules and Regulations, and all applicable California State Laws, <br /> Signed x al.a Thie/Company P 'ec# eY' U R Cp, of a Sri <br /> Print Name o.1-. v r-e-� Date Io� pY <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: /J <br /> Application Aooepted By Date Issued / Z <br /> Destruction Inspection By <br /> Grout Inspection By '�BaL-L <br /> ��_._,_„Final Inspection By Date <br /> Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> FAC# <br /> PE CODES _FEE INFO AMOUNT REMITTED CHECK# i <br /> p REC D BY DATE PERMIT I SERVICE REQUEST# INVOICE <br /> 4D 0 <br /> -57_ WC -WAIVER,_ C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />