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01/07/2003 14 25 4640138 ENVIRONMENTAL HEALTH PAGE 02 <br /> WELL, PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> I304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 46$,3449 <br /> INON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application Is hereby made to San Joaquin County for a pelma to construct anchor install the work described This application is made In rofnpliance with San <br /> Joaquin County Development Title,Chapter 9-1115 3 and the Standards f San Jo urn County Enwonmerital Health peparht�enL <br /> WELL LocaBon a��� £l_ Crass Street Q%hIk4:V�, City Assessor's <br /> ]]�� �} 0 f ,f�n �/�i�Is7/�Zrp PBrCef# _45-2-21� <br /> I PROPER"IYOum2r V+R�U� /+a! C �pRf���dress�..�1- Qnn //J3 — -- Crty5rccFi TD Zip9S�o phonal#2Q� yw� 2 <br /> cw?Contractor ' f 1 r Address -5'560 5, IAI�r:/ i aty-4C/40P bpW 26 1.�c 6 7.�6I7 Phona#9l 63/^3 u <br /> 1 ^ <br /> Gonsultant;l Sub Cntr�, �, � - _ ,._.Address ��� �l!g,v�f IQ�,+ Crty�K�n�t,c# b�a� <br /> f�6a��,Pr+onev Z? <br /> GIS Coordinates X Y ,Township Range +U E_ Section ----- <br />' WORK To BPERI±ORtNLtJ <br /> NEW WELL 1 BORING(CI'T,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER-) U DESTRUCTION (chnow type bclaw) <br /> RSOIL BORING# p OVEN-BORE <br /> WELL# Grout Spe <br />' RESSURE GROUT"other^ vf'icai,ons 4 <br /> COMMENTS .S C r_— <br /> A s5 <br /> TYPir OE.MLL INSTALLATION TYP CONSTRUCTION SPECIFICATIONS */ <br /> ?MONITORING HOLLOW STEM DIA OF BOREHOLE /J5 a MULTIPLE CASINGS?13 MULTI-LIEVEL?p WELL CASING DIA__- <br /> [I EXTRACTION S4h� It <br /> Q AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING 11 STEi=LNE <br /> VC aOTHERVAPOR Q MUD ROTARY DEPTH OF GROUT SEAL T1 EM1E TYpE TO OE L3 AUGERS a HOSE <br /> SPARGE/Ozone PUSH POINT GROUT SEAL PUMPED -)q <br /> p No (NOTE MAXIMUM FREE-FALL DEPTH IS-101 <br /> 1 SOLI.BORING 1j HAND AUGER GROUT SPECIFICATIONS 40-1 �t] 7_00 <br /> []OTHER _ I OTHER APPROX BORING DEPTH ABOLTED TRAFFIC BOX or [I STOVE PIPP <br /> CONDUCTOR CASING PRC3POSr=D') &D (if YES,Irst speoficanons here) <br />' 'COMMENTS SF F 1. T,a RAID (- Aed P06 Z. <br />' NOTE. OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS <br /> I hereby certify that I Dave prepared this application and that the work will be done In accordance;with San Joaquin <br /> County Orth ances, Rule 2ind Re Mations, and all applicable Callfaim tate Laws <br /> Slgnad x - itte/Company Q EC7� s ' <br />' Print Name C v �� Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN BATED' <br /> AppiicaifOn Atxepted t3y bate Issued Area <br /> Grout Inspection By Data Final Inspection By Data <br /> pestructlon inspection By ©ate <br />' COMMENTS I CONIQITIOMS A <br /> r� ` <br /> COUNTING ONLY AID# <br />' PE C013.ES KITE INFO AMOUNT R>EMMO CHECK# Rwvyt DATE PERMIT!SERVICE REQUEST# INVOICE <br /> C-57 WC ..WAIVER, C-57 letter of Author o sign permit 6ncroochment doc 8/29/02 <br /> 1 <br />