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10/08/2002 10:47 2094683433 FIFTH FLOOR PAGE 04 <br /> SEP 0 7 2004 WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY <br /> Vl :, E 111EALfH ENVIRONMENTAL HEALTH DEPARTMENT (EHD) MITIGATION <br /> IT <br /> 1'ic'ENVICES 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 /> Appllntlon is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development T7tle,Chapter 9-1115.3 and the Standards of San Joaquln County Environmental Health Department <br /> (;a.l'1YA 3 0.CG¢.S i (D c:-J, N. <br /> WELL LocationC r+}31 - S+ix-t'I' a- Cross Street '�Q Vn in lodr HS240 Assessors <br /> City lip Parcel# <br /> PROPERTY Owner C-wl Tri"s Address 670 G o x 20't6 CityS �-K tan Zip!zal Phona#— <br /> C-57 Contractor (rr2.gd 9r;Ili n.�dress q� I"�w e 2c� city Ho-r-�'ne�-rp9Y5S3 Lic#ds o7Phone# (92 s) 313-5$00 <br /> —1f, <br /> J <br /> Consultant/Sub Cntr I (RL I 5a( Sty A <br /> Addreu_ .Q u-K city Co n r o�-r�- Or# Phone#(4 Z S)b g$"-1 zo d <br /> GIS Coordinates:X ,Y.Township 3 f Range--6 ,FSection 13, <br /> WORK TO BE PERFORMED: <br /> IKNEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER•) 11 DESTRUCTION (choose type below) <br /> 0 SOIL BORING# <br /> DOVER-BORE- DIAMETER <br /> DWELL# aPR <br /> W-Ofher &fl- 2 ( c pT c,-7 ,�,p ) PRESSURE GROUT <br /> - GROUT SPECIFICATION <br /> COMMENTS: S <br /> TVPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS ^^') <br /> S MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE_2L 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:N <br /> n EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS N/A TYPE OF CASING: n STEEL n PVC n OTHER: Nl A <br /> n VAPOR 0 MUD ROTARY DEPTH OF GROUT$EALSn ii- Go-1�+1(rTREMIE TYPE TO SE USED: n AUGERS n HOSE <br /> n AIR SPARGE)OZONE lit PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes n No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> 17 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS Newt Ck- e,..J- <br /> VVTHER: C r^7- n OTHER APPROX.BORING DEPTH 13Z {t 0 BOLTED TRAFFIC BOSTOPIPE <br /> CONDUCTOR CASING PROPOSED /V O (if YES,list specifications in Comment section) <br /> COMMENTS: , <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. Z <br /> 48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. o <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County inances, Rules an gulations,and all applicable California State Laws, <br /> Signed x ze, <br /> ��-r--f-- Title/Company f <br /> �+'t <br /> PrintName 4,j-J (AA-4-t;'Vim+ J9JL/L) ¢, <br /> Date / <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS= <br /> WORK PLAN DATED: Q � y <br /> QPPlication Accepted BY Date Issued lC!by Brea-lj-L_L_L�LJ�'B <br /> 3rout Inspection By Date 2 LI U Final Inspection By _T Date <br /> Destruction Inspection By Date ' <br /> :OMMENTS I CONDITIONS: C-�T <br /> ACCOUNTING ONLY-- AID# - FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 9bl �` fes$ fJK 9 /v p SR# 58o <br /> C-57 WC_-WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />