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06/05/2002 08:53 209468='^13 FIFTH FLOOR PAGE, 02 <br /> WELL PERMIT APPLICATION FORM D SITOlrriON <br /> E <br /> MC� <br /> SAN J <br /> OAQUIN COUNTY UNIT <br /> IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) JUN dna <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 ENUIROM1EN1 HEALTH <br /> PERMITiSERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEA FROM DATE ISSUED <br /> Application <br /> pl' nlheDe Development San Title,(Chapter 9-1111for a permit to construct 5.3 and the Standards da ds of San Joaqor uin)County me kEnv'ir Environmental Health llDepartm node in compliance with San Joaquin CountyWe .L�0.Sh�>^�W��t' Assessors <br /> 2�0� Parcelil <br /> WELL Location Yl . Cross Street K S�Rd_City cS oGk't0 �`—�p— <br /> PROPERTY OwnAr ++ Address <br /> P IP hone#City G!G In ZipQ Z0� q"' O 2�b <br /> C S7 Contractor �1 Address Q Ci Q Zip4kdLji JSL.1t�=Phone# 3 00 <br /> I? ` ��. City �AV� Lic# Phone# ^(f� 8� <br /> Consultant!Sub Contractor�) �S Address,�QQ��, <br /> Y <br /> Township Range Section <br /> GIS Coordinates:X_ <br /> WORK TO BF PERFORMED: Q DESTRUCTION(choose type below) <br /> �NcW WELL. E BRING(OPT, <br /> CPT,GEOPROSE,HYDROPUNCH,HAND-AUGER,OTHER') " I C [I OVER <br /> 0 SOIL BORING# `g� C rP-yr ?0 Gl 1t g\` `��[I PRESSURE GROUT <br /> JELL# — )� <br /> ' Grout Specifications <br /> 'Other._ <br /> COMMENTS: W C <br /> TYPE OF WK—LL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> �Qj A10NITORIt�; yHOt_LOW STEM DIA.OF BOREHOLE$_MULTIPLE CASINGS?0 YES �NO WELL CASING DIA:_4Z" <br /> 11 EXTRACTION [ TYPE OF CASING: 0 STEEL PVC 1)OTHER: <br /> ;,.IR HAMMERJDRIVEN CASING THICKNESS <br /> I1 VApnR jl MUQ ROTp.Ry DEPTH OF GROUT SEAL Ol h TREMIE TYPE TO BE USED: p[LAUGERS 0 HOSE <br /> n AIR SPARGE I!PUSH POINT GROUT SEAL PUMPED: es etNo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL enF?ING t',HAND AUGER GROUT SPECIFICATIONS: BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> fl OTItER: j)OTHER_ APPROX.BORING DEPTH raC <br /> O �� <br /> CONDUCTOR CASING PROPOSED?_S(iiVES.list specifications here): <br /> if <br /> 'COMMENTS: `r 1 <br /> NOTE: OFFSITE SORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> rni i_ r F,r= t—� Ir;I; jv I,�;F Fr,TOft 48`CORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance With San Joaquin <br /> rnurty c+r iir nnr es, t,,Iles Orel I7egU!.-4i0ns, and all applicable California State Laws. t ` <br /> Stoned x A 41 a Title/Company ASS - y\ <br /> Dat <br /> Print Name-5�aj DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> f 2-011t. <br /> WORK PLAN UA7FU: <br /> /r _�/ / Date Issued_ <br /> (,�2 D Z Areafll l'l� A/dLl� <br /> Application Accepted Eiy Atf `� �' Date_ <br /> Grout Inspection By <br /> Date— <br /> Destruction Inspection Dy Date <br /> COMMENTS I CONDITIONS: <br /> ACCOUNTING AIDA' cnrit <br /> PE Cn�F_5 1 FFE 1NFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT)SERVICE REQUEST INVOICE <br /> SSD 1 i— �� 0 3 ?O lJl� t�z� oma- SRI DI v 3� <br /> C_57. _ NJ(- -W,I (VER____ C-57 Letter of Authorization to sign permit Encroachment doc 1/25/0, <br />