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12/23/2005 11:50 2094683433 END PAGE 02 <br /> 1J <br /> T <br /> WELL PERMIT APPLICATION FORM 1-010 & S1 : <br /> I SAN JOAQUIN.COUNTY MITIGATION. <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> �l/"/ rpt- S� <br /> ON-REFUND BLE PERMIT XPIRES 1 YEAR FROM PATE ISSUED <br /> Applir�tion is hereby made San Jodquin County Tor a permit to Construct andlor Install the work described, This application Is made in compliancx w{ttr <br /> Joaquin County Development Ttt+P C ha°ter 9-1115.3 and the Standards oT Sart Joaquin County Environmental Health DepartmentAssessors <br /> WELL Location Cross Street <br /> city Zp?526> d Parccel# o n -�c.-lv <br /> 7 C,R { -2ip`� i s�rPhone# 1/Z y 2 6`�E> <br /> J (1 � c� a ddress ff S L � c� City <br /> PROPERTY Omer 2 bs,S G, „ %/I, Y 3 y 42C30 <br /> + <br /> Z- ( I� tv-e CityQ c ,MI)�%>d 7�LCt rphorp___ <br /> C47 Contractor <br /> 9f; � dress�Y�3 • .r;.-a- <br /> Phone* <br /> U Address tatty Lic#�— _____� <br /> Consultant/Sub Cntr � <br /> �. ,Township Range <br /> GIS Coordinates:X <br /> WORK TO SE PFRFO,RMED_ <br /> I]NEW WELL I BORING (GPT,GEOPROBE,HYDROPUtuCH,HAND AUGER OTkER) p Dia O�BCREN DIAMETE�below — <br /> `OIL BORING# p PRESSURE GROUT <br /> WELL# GROUT SPECIFICATIONS <br /> p-other L <br /> COMMENTS: <br /> C�NSTRUC710N SPE-CIFICA710N5 ` <br /> TYPE OF WEL INSTACA <br /> L TION TYP IA.OF BOREHOLE Q MULTIPLE CASINGS U MULTI-LCVEL WELL CASING O� L <br /> a MONITORING OLLOW STEM G K PVC Q OT}-;_ <br /> AIR HAMMEPMRIVEN CASING THICKNESS / TYPE OF CASING: t1 STc_L [] <br /> FXTRACTION a ( a TREMIE TYPE TO BE USED: UGERS 0�05cJPWL <br /> Q VAPOR a MUD ROTARY DEPTH OF GROUT SEAL � <br /> SEAL PUMPED: D Yes o No (NOTE- MAXIMU FREE-Y AL DEPTH IS 3Q"j <br /> �AIR SPARGE/OZONE []PUSH POINT(GP or CPT)GROUT ;�,� z-:' �- f , J <br /> ,)kSOIL BORING HAND AUGER GROUT .BORING <br /> I G OEP S- `` <br /> OTHER APPROX.BORING DEPTH L�l^ � II BOLTED TRAFFIC BOX d' �STOVE PIPE <br /> p OTHER:�� — rf YES.list speCillCdSonS in comment Section) <br /> CONDUCTOR CASING PROPOSED ( <br /> COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS REQUIRED FOR INSPECTIONS,ENCROACHMENT PERMITS. <br /> 48 WORKING HOURS NOTICE <br /> I hereby certify that I have prepared this application and that the work will be done in accordance auitt.San Joaquin <br /> County Ordina s,Rules a <br /> Titic/ComhanY <br /> and all applicable California Stats Laws. <br /> Signed x7ulations, <br /> ' <br /> 9 - Date av— <br /> prfnt Name <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED' <br /> Date issued <br /> Application Accepted 6Finat Inspection By Data <br /> Grout Inspection BY Date <br /> C;oe uction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# FAC# <br /> pp CODES FEE INFO AN17T REMITTED CHECK# REC'D SY DATE PERMIT I SERVICE R/E/QUEST# INVOICE <br /> C` i � y 3ti�02 <br /> C-57_ WC;WAIVER— C-57 Letter of Authorizatioh to sign permit,Encroachment dor— <br />