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03/27/2003 10:57 209458343- FIFTH FLOOR PAGE 02 <br />WELL PERMIT APPLICATION FORK! <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 />NQhEaFUNDABLE PERMIT III IRE31 YE49 FROM DATE ISSUED <br />Application is henry made to San Juan County for a permit t0 Construct and/or Install the work described. This *"11031on is mace in compliance with Ur <br />Joaquin County Development Title, Ch*pter 9-1115.3 and the Standards of San.loaquin County Environmental Health Department. <br />/ Assessors <br />1MELL Location _ � �. �� /�O(� ode Crosa SStreet l / City SST L�9 0� Pamd# / % —� �� O �i <br />PROPERTY Owrer&x o" 5-7tx To �t Addre/s�al���.0 �jJO City SZ� Zip y�O�Phona# Y� 2da y <br />C-67 Cnntreclor 4 1G, Address40,0 v�� �i 14&1 cd lazlp Cy df?lop Phone#t c1Zi Z71-7 y1aa <br />Consultant ( Sub cn 4 �' ✓ Addres5v2Y37 ,,. r•rli,. cicy�I�u�Phone� �i �'O.Z p3 <br />GIS C=dirlsUs: X Y Township Range Section___. <br />WQRK TO BE PERFORMED: <br />)KNEW WELL 1 BORING (CPT, GEOPRoBE, HYDRCIPUNCH, HAND -AUGER, OTHER*) U DESTRUCTION (choosetvpe below) <br />0,301L BORING # p OVER -BORE. OIAh1ETER <br />,'WWELL#_y" X14 Ori'' S�a p PRESSURE GROUT <br />U'Other GROVT SPECIFICATIONS <br />COMMENTS:__ (� t <br />C <br />TYPE OF WELL INSTALLATIQN TYPE CONGTRUCTION SPECIFICATIONS <br />a MONITORING tiOLLOW STEM DIA OF BOREHOLEZ-& 0 MULTIPLE CASINGS o MULTI-LEVEL WELL CASING DIA <br />Q EXTRACTION Q AIR HAMMEWDRIVEN CASING THICKNE 6 4 TYPE OF CASING: p STEEL XPVC Q OTHER: <br />,MVAPOR Q MUD ROTARY DEPT --I OF GROUT SEAL — TREMIE TYPE TO DE USED. D AUGERS Q HOSE <br />rn <br />)AIR SPARGE/ OZONE a PUSH POINT (GP or CPT) GROUT SEAL PUMPED: Q Yea p No (NOTE: MAXIMUM FREE FALL DEPTH IS 30') <br />p SOIL BORING 0 HANC AUGER GROUT SPECIFICATIONS <br />Q OTHER: U OTHER_ APPROX, BORING DEPTH 5?/ OOLTED TRAFFIC BOX or a STOVE PIPE <br />ONDUCTOR CA91NG PROPOSED YP.s, list specifications In comment section) <br />.f.p � - <br />1 <br />GOLIMENTS: re1v e r- fir 1_5 <br />NOTE: OFFSITE BO GS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have preparod thi$ application and that the work will be dotes in accordance with Sen Joaquin <br />County Ordi nme s, Rules and Regula ons, aril all applicable California State Laws„ <br />Signed x Titie/Oompdnyy O Sr/1T[? sr / <br />Print Nam• L �" Data <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted By oats Issued Q MAR 2 5 2004 1 � Or <br />Grout Inspection By Date Final Inspection By pts <br />Deslruction <br />Date <br />COMMENTS 1 CONDITIONS: , -k'y 2�C1�+e. /.-n /IZ..nn.. A.I� dl �� #fit C L ,Cl 3� — t .U.t � � JLt,� t G. LJ2iT L' <br />ACCOUNTING ONLY: I AIDW I PAC# <br />PE CODES F E INFO I AMOUNT REMITTED CHECK # RECD EY DATC PERMIT / RVICE R i INVOICE <br />RO �17 <br />C-57_ WC= WA1VER_ C-57 Latter of Authorization to sign per>Svt_ _ 9/30/02 <br />