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Q2/19/2002 16:12 20946E 3 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY ° T' ' -LUlN <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 FFF2 8c <br /> (209) 468-3449 <br /> ENVIRON"r'ENT HEALTH <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERS,` 'E4" FS <br /> 4pplicaticn 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 Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessor's <br /> JVIELI-Location /ygla/E. .S121a O Cross Street CityA <br /> WicrJ6xcJde,Zip-ParceI# <br /> PROPERTY Owner(,a�>Sans/GwcvlWc l�l.l�s Address 197&W- e"r�cr WckV City S4ock4on Zip 5205 Phone# R(p9-9V8--7 <br /> C-57 Contractor Address /,/an �'ok�� SO}t" City •clnme�Zip9ygOc/lrc#b3to337 Phone# 5/o-�3'7-4157S <br /> ConsultantISub Contra ctor X-T eor�orat►on Address/ZR& 1VVMcArL 9L /-Ciry.�ocravx¢niU Lic# Phone# -3300 <br /> :SIS Coordinates:X ,Y Township Range Section <br /> NpRK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) n DESTRUCTION(choose type below) <br /> 11WSOIL BORING# Co a OVER-BORE <br /> WELL# (j PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> :�OMMENITS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> [j MONITORING [I HOLLOW STEM DIA.OF BOREHOLE _MULTIPLE CASINGS?a YES xNO WELL CASING DIA- <br /> ]EXTRACTION ,(AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL n PVC O OTHER: <br /> ]VAPOR [I MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ()AUGERS 0 HOSE <br /> ]AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: p Yes p No (NOTE: MAXIMUM FREE-FALL DEPTH IS 301) <br /> SOIL BORING Q HAND AUGER GROUT SPECIFICATIONS: <br /> ]OTHER: p OTHER APPROX.BORING DEPTH /0 mL�cr s 0 BOLTED TRAFFIC BOX or G STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (If YES,Ilst specifications here): <br /> 'COMMENTS: <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> CountyyOOrdinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x "l - Ax^e, Tide/Company <br /> Drint Name i'�lGl./ (� �d u Date L 1 1 0"L <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: <br /> %pplication AcceptedDate Issued alt n Area-, /c c� <br /> !rout Inspection By Date b Z Final Inspection By Date <br /> destruction Inspection By Date <br /> -OMMENTS/CONDITIONS: vc 1 t '._.{,+ .., <br /> ACCOUNTING ONLY: AID# <br /> tnr`� <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC°D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit_ Encroachment doc 1/25/02 <br />