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10/08/2002 10: 47 2094683433 FIFTH FLOOR PAGE 04 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> SEP 0 7 2004 304 E. Weber, Third Floor, Stockton, CA, 95202 <br /> ENVIIIONi'vIENT HEALTH (209) 4683449 <br /> P'-', SAI F'SERVICFs NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Application is hereby made to an 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 Tltie,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department <br /> WELL Location 143j S. 5LkO+l 5t. cross Street—K �o Ity !-c di zip 95: PaceAsses#o(,z 0s' 1 - 02- <br /> PROPERTY Owmer-A H I I k +'" Cp. Address 10 5. A V e ri a Aft City-La- , Zie�Phone# <br /> C-57 Contractor ie 0nll:an Address T33 RA City Maf oe-z zipqtsv3Lic#010 Phone#(4LS) 313- 5"800 <br /> Consultant/Sub Cntr TRG Address 15 .050(�� S City Cont-oma Uc#// Phone#(k?a)68`6-12-pd <br /> GIS Coordinates:X 'y .Township 3 tj Range F- Section l 3 <br /> WORK TO BE PERFORMED: <br /> p NEW WELL/BORING (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') p DESTRUCTION (choose type below) <br /> a SOIL BORING# n OVERBORE_ DIAMETER <br /> 0 WELL# - n PRESSURE GROUT <br /> jZ'Ofher /.l+T-'zR LrT (S��� w) GROUT SPECIFICATIONS <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> n MONITORING n HOLLOW STEM DIA.OF BOREHOLE ZL 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA:N�_ <br /> n EXTRACTION n AIR HAMMERIDRIVEN CASING THICKNESS Ai A TYPE OF CASING STEEL � <br /> � [� PVC nOTHER: /J�A 'IN <br /> n VAPOR n MUD ROTARY DEPTH OF GROUT SEALE_-1 vi).,- .d TREMIE TYPE TO BE USED: n AUGERS n HOSE <br /> n AIR SPARGE/OZONE 0 PUSH POINT(GP or CPT)GROUT SEAL PUMPED: n Yes p oN NOTE: MAXIMUM FREE-FALL DEPTH IS 30') _A <br /> n SOIL BORING n HAND AUGER GROUT SPECIFICATIONS What +i o-6 6,. L..Y�..rO P,A„� ro '<f ' <br /> )t OTHER: CYr n OTHER APPROX.BORING DEPTH Iso ♦ []BOLTED TRAFFIC BOX or ]]STOVEPIPE <br /> CONDUCTOR CASING PROPOSED A)o (it YES,list specifications in comment section) V <br /> COMMENTS: s <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 /> Coun Ordinances, Rules a egulations,and all applicable Califomia,S(�(+.r'-�to�Laws. /�� ,, n , <br /> Signed <br /> Print Na !✓FvFI^^'J �/J Date 9/Zr0 �- <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED//: <br /> Application Accepted,Dx U t Date lssued �0%y Area% -7 L-2 -60 <br /> 3rout Inspection By NL Date 121q1014 Final Inspection By T Date <br /> 7estruction Inspection By Date —1 <br /> COMMENTS I CONDn10NSt C W <br /> ACCOUNTINGONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INYOICE <br /> ,I K ro SR# Doi S7 <br /> C-57_ WC=WAIVER_ C-57 Letter of Authorization to sign permit_Encroachment doc_ 9/30/02 <br />