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08/20/2003 09:58 2094683433 FIFTH FLOOR HAUS 02 <br /> 04/10/2002 15:36 20946$3433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> SAN JOAQUIN COUNTY MITIGATIQN <br /> ENVIRONMENTAL HEALTH DEPARTMENT (F-HD) UNIT IV <br /> 304 E. Weber, Third r)Qor, Stockton, CA., 96202 <br /> (209) 46"449 <br /> NON-12EFUNDASLE PIFIRMIT EXPIPI±S 1 YEAR FPbm o HUED <br /> Application Is herby made to San Joaquin County fora permit to construe and'orinstall the work dssciibo4�, This application is made in compliance with San <br /> Joaquin County DevelopmentTiUe,Chaptor!-9i15.8 and the Standards of n Joaquin Cauniy viranmenta(Health l7epartrnenL <br /> Vo.��o +�xu c��a Eiev, a'.v w► t, s: o b u�^d�w�.2-oma Assessor's <br /> WELL Location 1qD yoNin wtnl ,l l� Cross Sireet <br /> �s ' �wrlr4. City _dip Parcell# 19tJ5d 10 <br /> Gl,...� 4.a-�•-�1. °-fiP'�"�-�• 6 v.,.A.Lxn ..,rcbt- cep <br /> PROPERTY Own l�sa 6 OOv�a�A7ptla„AddrG55 Gty. SfOC�C�vvtprp 95."Phone#f <br /> G�C7COntraCrrx V$_W Q7ci�i ,Xrt_Address t�L, S1-rt_a.� e•O.Q,ox' ty �ylaabn ZrpgSGytLici#"1�o4oyPhone 4lDO <br /> J <br /> Consultant/-Sub CoatradoreH-Lnr, L Addresst'35 CA--y'& (aNC• Clty0o.k10.r,d ucli hpnq 5tb�ltq-SR 8-I-C4LSV.i-AGCIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED- <br /> 0 NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHEtr) �ESTF2UCTION(Choose typo below) <br /> d SOIL BORING# <br /> VQMVER�ORt: <br /> U WELL p PRESSURE GROUT <br /> 'Othrri Grout 9pecl(icatlons: <br /> COMMENTS' \,,4oJ a-N AA—jm ax L ds,9�r�•c SEak�o,, w0J crew -� Mw-R �nw-1O <br /> TYPE OF WELL INSTALLATION TYP CONSTRUCTION SPECIFICATIONS <br /> V$'MONITORING 17 HOLLOW STEM DIA.OF BOREHOLE __., MULTIPLE CASINGS?[I YES Ij NO WELL CASING DIA: <br /> 0 EXTRACTION 0 AJR HAMMERIDR[VEI" CASINQ THICKNESS TYPE OF CASING, I]STZEL Q PVC BOTHER: <br /> n VAPOR B MUD ROTARY DEPTH OF GROUT SEAL TREMII 'TYPE TO BE USED: n AUGERS 11 HOSE <br /> IR SPARGE p PUSH POINT GROUT-SEAL PUMPED: a Yes B No (NOTE:MAXIMUM FREE-FALL DEPTH IS 30') <br /> .OiLSORING (j HANDAUC-ir-'k GROUT SPECIFICA'nONS: <br /> a OTHER;rl OTHER APPROK'LORING DEPTH (]t30L-IED TRAFFIC BOX or a STOVE PIPE <br /> 'COfu1MENT5: <br /> CONDUCTOR CASING PROPOSED? (If YES,list spedHldatlorts here): <br /> NOTE; OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPEG=NS_ <br /> I hereby certify Oat I have preps this application and that the work will be done in accordance with San Joaquin <br /> County O dinanG s,RU! arl SU[ations,and all aPPI'Ctable California State Laws. <br /> sign" � THIel mpa / <br /> Prim Name = ,JchrY o ' ~� <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> VVORK PLAN DATED: <br /> Vplic4on ACnopcad Ry. AlADate Issow <br /> Ata <br /> 3routtnspeCfion BY to Final Inspection lay —Date <br /> 7ostrvction InspOCUon By Date <br /> :oMN1ENTS 1 cQNDmorls: . <br /> w1 <br /> ACCOUNTING ONLY_ AID# <br /> cmrr+ <br /> .CODES FEE INFO AMOUNT REMrt•TED CHECK F REC'n BY *DIAPl�MIT 1 SER'AGE REQUEST# INVOICE <br /> 0. 001 1Z z I <br /> C-57 WC=WAZVEi.• c-57 Utter of Autho ze ' sign permit—Encroachment doc•,_ 1/25/02 <br /> , I <br />