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021`0 3/ 20031 14: 35 2094683433 FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM SITE <br />FEB 2 A 2003 SAN JOAQUIN COUNTY MITIGATION <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />ENVIRoNNIENT HLi� .' 304 E. Weber, Third Floor, Stockton, CA., 95202 UNIT IV <br />PERMI'f/SERVIt:;E`3 <br />(209) 4683449 <br />NON-REFUNDABLE PERMIT EXPIRES -1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or Install the work described. This application is made in compllance with San <br />Joaquin County Devp/llopmC,ent Title, Chapter 9-1115.33 and the Standards Of San Joaquin County EnVironmentat Health Department, <br />WELL Location' /1t n, „-Wx Lam. Cross Street 1ZL City f(,� Assessors, <br />,p �/ / � ,./ Zip �--Parte(# �}j •-IffC — .) L <br />✓ i C'&-1 rw f Address �eNt%1 ✓/%PSS/ Clry z� ' -Se ✓� <br />PROPERTY Owner 1 Z✓ 'Cid p rj��( Phone# <br />C-57 Contractor v✓�i�/ty f�A//, Addressoj0/�/ f Zi >/Ltc# 1�,� Phone <br />ct p q 767 3 - 5� 00 . <br />Consultant /Sub Cntr_ �/r / ��/ _Addressb /0 CGyt-y a,� 0,64Gity�Lic# Phone# /lC C�p-')Ooo <br />GIS Coordinates: X Y Township Range H /"' Section <br />WORK TO BE PERFORMED: <br />EEE INFO AMOUNT REMrrTED <br />0 NEW WELL / BORING (CPT, GEOPROBE, <br />HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (choose type below) <br />0 SOIL BORING # <br />� WELL # /%� iti/ �� <br />a OVER -BORE. DIAMETER <br />'Other <br />0 PRESSURE GROUT <br />COMMENTS: <br />GROUT SPECIFICATIONS <br />TYPE OF WELL INSTALLATION TYPE <br />CONSTRUCTION SPECIFICATIONS <br />MONITORING 0 HOLLOW STEM <br />DIA. OF BOREHOLE �w 5-(] MULTIPLE CASINGS n MULTI-LEVEL WELL CASING DIA, <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN <br />CASING THICKNESS TYPE OF CASING: H STEEL IFPVC D OTHER: <br />[] VAPOR 0 MUD ROTARY <br />DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED. M AUGERS 0 HOSE <br />n AIR SPARGE! OZONE n PUSH POINT (GP or CPT) GROUT SEAL PUMPED: R Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301) <br />0 SOIL BORING 0 HAND AUGER <br />GROUT SPECIFICATIONS I)e.,I- <br />0 OTHER:_0 OTHER <br />APPROX. BORING DEPTH I &0 _1BOLTED TRAFFIC BOX or O STOVE PIPE <br />/ <br />COMMENTS; �P �// ( <br />CO DUCT9R CASING R POSED ✓ (if YES, list specificatian5 in comment section) <br />CV y�v <br />. <br />�' s: l - �U <br />NOTE: OFFSITE EORI GS REQUIRE ACCESS AGREEMENT OR ENC OACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS <br />I hereby certify that I have prepared this application and that the work will be done in mr_er rrinnt-a —ith came. t..�,...:.. <br />Count, <br />3igncd x <br />'Int Nar <br />>ITF MAP IN UNIT IV FILE, ADDRESS: <br />NORK FLAN DATED: <br />�pplicatian Accepted By d Date IssueIO Area <br />3rout Inspection By__4 Date 3 i, Final Inspection By Date <br />testruction Inspectlon By Date <br />:OMMENTS / CONDITIONS:_ O btu O'Y\- 4 t Q 1Ut W A&) [J) P S�tj <br />ACCOUNTING ONLY. I AID# _ I FAC# I II <br />PE CODES <br />EEE INFO AMOUNT REMrrTED <br />CHECK # REC'D BY <br />DATE PERMff /SERVICE REM # <br />INVOICE <br />6S2_30 ( <br />a LSR# 6 p 3L? <br />-:) i_ W(_= WALVLR___ . C-57 Letter of Authorization to sign permit Encroachment doc 9/30/02 <br />