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01/06/2004 12:37 2094683 FIFTH FLOOR PAGE 02. <br /> ^ WELL PERMIT APPLICATION FORM SITE SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT EHQ MITIGATION <br /> 304 400' 304 E. Weber, Third Floor, Stockton, CA.,"95202 UNIT 1V <br /> C r,i`S1�if;�tUiJi 1! HEt AIH (209)46$-3449. - - - <br /> FI ?I`Vf1�ISER�!$G{m5 MQN--REFUNDPMLF-F!ERMITI piaes f YEAR FR AT#-ISBU D <br /> Applic2titn is hereby made to San Joaquin County for a permit to construct and/or install the work described. This awicetion is mada in compliance with San <br /> JQaquln County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> WELL Location ��a cY 01'r 4 Cross Street 0��"f City ��4� 7�p �� Parcell r� <br /> PROPER - <br /> Owner. TYS� Lut� utkddressa�jZ��LI"�cT" ;l �aE. <br /> ZIP`t5r {v <br /> - y F}hone# y <br /> Cs7 Contractor 'IY9VI4t, Address City z <br /> GarrsPIMMr Sub Cntr �- M50c� -} Address _ City�_ Lida Phone#, <br /> CIS Coordinates:�_ Y Township Ranps Saetion <br /> WORK TO BE PERFORMED- <br /> IEllif WELL/BORINGCP PR013 HYDROPUNCH,HAND-AUGER,OTHER") 1]DESTRUCTION (choose type below) <br /> g$011 BORING#- - p OVER-BORE. DIAMETER_ <br /> a WELL# --- Q PRFSSURE GROUT <br /> Q"Other GROUT SPECIFICATIONS <br /> CQMMENTS: e- <br /> TYPE:,OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> D MONITORING Q HOLLOW STEM DIA.OF BOREHOLE Q MULTfPLE CASINGS U MU"LTI-LEVEL VVELL CASING DIA: <br /> 11 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS- _ 'TYPE OF CASING' O STEEL. Q PVC n OTHER: <br /> Q VAPOR p MUD ROTARY DEPTH OF GROUT SEAL TRrFMIE=TYPE TO BE USED: p AUGERS u HOSE <br /> Q AIR SPARGE/OZONE USH POINT aor,GPT)GRCUT SEAL PUMPED; n Yes XNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> OIL BORING tJ HAND AUGER GROUT SPECIFICATIONS <br /> 11]OTHER;"_ 11 OTHER APPROX,BORING DEPTH Imo'9$p BOLTED TRAFFIC BOX or .0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED Of YES,list specifications in comment seoticn) . <br /> COMMENTS, <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT'PERMITS. " <br /> AS WORKING HOURS NOTICE RFQUIRED FOR INSPECTIONS. <br /> I hereby certify that t have prepared this application and that the work will be dodo in accordance with San Joaquin <br /> County Ordin Vices, Rules and Regulations,and all applicable California State Laws. /1 <br /> 111rrSigned x "Title/Company j5rIV, t e4t h.S4 <br /> w� Print Name aM C { Date I �O <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADD E53;� 4D.. `1 ^ oL L to L <br /> f WORK PLAN DATED: <br /> ApplicationAccepted By I Date Issued .; LoI Ll <br /> Grout Inspection By bate . Final tnspactian By_: ,,,_Date <br /> Destruction Inspection My pg#e <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT RE CHECK.# IiEC'D 13Y DATte PERMITJSERVICE REQUEST INVOICE <br /> SR# <br /> C-57 WC-_,,,,-WAIVED— . ,C-57 Letter of Authorization to sign permit=Encroachment doc " 9/30/02 <br /> a <br />