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09/25/2002 13:16 <br />ED, <br />MAR 1 8 2004 <br />209468'n33 <br />FIFTH FLOOR <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />PAGE 03 <br />SITE <br />MITIGATION <br />UNIT IV <br />ENVIRO[WiiCH0 HEALTH (209)468-3449 R I N 1-% L <br />PFRMI T /SFRVICFS 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 appllcation is made In compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department_ <br />CCN t 1 t'/} RkING' Alt►iL E <br />Assessors <br />WELL Location 13,13 N, i V,-4 t L K S T. Cross Street C w 3 K h� t'Clry J TCc h f h1 Zip 95 Zii Parcel# 13 9! 2 0 0 2 <br />aAN1 ta�tN Ci,�tyTV <br />PROPERTY Owner FALiliS My -MC. Q V - Address l }12 I:.Sf G fI Ati t: City 5FCCK i-Giy Zp3 5ZO'1 Phone# IZG J) <br />;/A4iBY <br />C-57Contractor FlS0 EKV li(;(A11F iVAl dd,,,s3-)) 'j fPI'5 PO4F CIN 5r'i�+ail Zlp`)i Lic#at &S Phone#(Z)1 3S }C <br />Consultant / Sub Cntr P\ A M A G -L Address i1 (, 13 C I( 1 :+ City RA N C I i C Lic# RC' Phone# <br />FNU1,6NMENf L, iNc . -K-171-11 Er <br />GIS Coordinates: X , Y Township Range Section <br />WORK TO BE PERFORMED: <br />II NEW WELL/ BORING ( CPT, GEOPROBE, HYDROPUNCH, HAND -AUGER, OTHER`) 0 DESTRUCTION (Choose type below) <br />It SOIL BORING # C*' ' ui G S 1 C` ` C 0 OVER -BORE <br />0 WELL # 0 PRESSURE GROUT <br />'Other: Grout Specifications: <br />COMMENTS { 3) c(V S(TIz (jFGI'i'Gl3F HSCl�InIG� MI'I►i51 G-t�CV40VVAt R <br />TYPE OF WELL INSTALLATION TYPE <br />D MONITORING 0 HOLLOW STEM <br />0 EXTRACTION 0 AIR HAMMERIDRIVEN <br />0 VAPOR 0 MUD ROTARY <br />0 AIR SPARGE / Ozone I PUSH POINT <br />SOIL BORING 0 HAND AUGER <br />D OTHER : -n OTHER <br />'COMMENTS: <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE 2`r MULTIPLE CASINGS? 0 MULTI-LEVEL? 0 WELL CASING DIA --P4 <br />CASING THICKNESS NA TYPE OF CASING: 0 STEEL 0 PVC U OTHER: N A <br />DEPTH OF GROUT SEAL TD = 3L, TREMIE TYPE TO BE USED: 0 AUGERS O HOSE <br />GROUT SEAL PUMPED: 0 Yes I No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SPECIFICATIONS: N k A T L E M E N T <br />APPROX, BORING DEPTH 1(:1 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? IAC (if YES, list specifications here): <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 />hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />'ounty Ordinances, Rules and Regulations, and all applicable California State Laws. <br />iigned <br />'nnt Na <br />k. - <br />`l <br />TI11e/Company Lf, N S'v , f A t1 T/ R /A M h C -C- F IV V i IZ a Iv P1 F N fA L <br />Date <br />;ITE MAP IN UNIT IV FILE, ADDRESS: 13C N, ti V N C r K 5 T IZ E E T S TC C K To N C A <br />'YORK PLAN DATED: M A R1� iA 1l i 't L Q <br />,pplication Accepted By Date Issued AA a rejt iq 2 pD 4 Area l j 59 <br />rout Inspection 8y dG rn Date k Final Inspection By V,'ct7y-,4 rn gDate 3 1 d V— <br />lestruction Inspection BY Date <br />OMMENTS / CONDITIONS <br />ACCOUNTING ONLY: I AID# <br />rerM <br />PE CODES FEE INFO I AMOUNT REMITTED CHECK # REC-D BY DATE PERMIT/ SERVICE REQUE&T, <br />3sot 89.ao 89. ooR# 003 7 2 <br />-57 WC` WAIVER_ C-57 Letter of Authorization to sign permit_ <br />INVOICE <br />8/29/02 <br />