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T,1-2002 07:53 20946834 A"I FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />PE CODES <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 compliance with San <br />CHECK # REG'D BY <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />INVOICE <br />iligh+ 0�' U-" Assessor's <br />, oa <br />WELL Location E/ntI� Dgra anA CkcnnP.l S�e4SCross Street City 5+0-14,44v, Zip 9sa.oa arcel# 05 d--// <br />// <br />PROPERTY Ownert4-!A OC S�ac-Klt0r>,6(-,d00 Address ✓! N El 0 5-] - City J`'fo--K-f!a h Zip 9SW R Phone# ("'11869'7 <br />C-57 Contractor 6ee3Q-Dr,AhY%Q ; TeS+iv�?Address 9.SO 4pale&I city ✓% ,4:, neeZlp 9q9-S-3Lic##`yP9"145 Phone#192S)7i3-5-ePao <br />Suik Sao <br />Consultant I Sub Contractor U RS Address SID 6afeW44 Phone# (4tQ 6717-.i600 <br />GIS Coordinates: X -Y Township Range Section <br />WORK TO BE PERFORMED: <br />(� <br />II NEW WELL / BORING ( CPT, GEOPROBE, HYDROPUNCH. HAND -AUGER, OTHER*) a DESTRUCTION (choose type below) <br />C <br />Q SOIL BORING t# U OVER-BOREfs <br />+ D <br />p WELL #jV�(AJ- Nl t l� VL1 ccJ-ILIvI a PRESSURE GROUT <br />`Other: Grout Specifications.- <br />pecifications:COMMENTS:TYPE <br />f <br />COMMENTS- <br />TYPEOF WELL \ INSTALLATION TYPE CONSTRUCTION SPECIFIc,ATIONS <br />r <br />MONITORING �a / I HOLLOW STEM DIA- OF BOREHOLE I ) MULTIPLE CASINGS? YES NO WELL CASING DIA_ <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS 5411 S% TYPE OF CASING: 0 STEEL I PVC 0 OTHER: <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: N AUGERS 0 HOSE <br />a AIR SPARGE n PUSH POINT GROUT SEAL PUMPED: [] Yes No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />a SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: NCR Cerylcn- - <br />0 OTHER:_0 OTHER APPROX, BORING DEPTH 63 1 111 BOLTED TRAFFIC BOX or 1] STOVE PIPE <br />CONDUCTOR CASING PROPOSED7 No (if YES, list specifications here): <br />nn <br />Q I R4 Iqn ��S% <br />'COMMENTS: SGS �rGv1 �C Wary- d1A� P� <br />p <br />�A <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 />I hereby certify that I have prepared this application and that the work will ,be done in accordance with San Joaquin <br />County Ordinances, Rules and Regulations, and all applicable California State Laws. <br />Signed z�- <br />Print Name Ve-r►.orl <br />SITE MAP IN UNIT IV FILE, ADDRESS <br />WORK PLAN W <br />Application Accepted <br />Grout In9peotion By ­ <br />O <br />DEPARTMENT USE ONLY <br />Destruction Inspection By Date <br />.. �1i� ►./fit _�>....� I �'.« . - ' �rr'�ll.�l.l.' ./ <br />ACCOUNTING ONLY: AID# <br />Gni-1r <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REG'D BY <br />DATE PERMIT! SERVICE REQUEST 1; <br />INVOICE <br />LL s o <br />, oa <br />°l <br />r� z /o SR 316 3 <br />C-57_ WC -WAIVER C-57 Letter of Authorization to sign permi oc_ 1/25/02 <br />