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06/'0512002 13: 54 2094683433 FIFTH FLOOR PAGE 02 <br /> WELL PERMIT APPLICATION FORM SITE <br /> MITIGATION <br /> SAN JOAQUIN COUNTY UNIT IV <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <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 compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department, <br /> �giAssessor's <br /> �,'• v`y' �,� Cross Street I�'"�`'k`hj�" tY SSC fc�` ZiP ''�'Parcel# <br /> WELL Location <br /> Zipl Phone#�Z'i3 <br /> PROPERTY Owner Ly j17yru Address <br /> r <br /> C-57 Contractor Address City Zip Lic# Phone _ <br /> Consultant/Sub Contractor S ( � 1 T,+o- " i aAddress_C>j�l$c✓z 2'\' City j�4-�""''- � � P <br /> Lic# hone# <br /> /^ <br /> GIS Coordinates:X ,Y ,Township Range Section r� <br /> W <br /> ORK TO BE PERFORMED: DESTRUCTION(choose type below) <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAtIGER,OTHER`) OVER-BORE <br /> 0 SOIL BORING# 0 <br /> WELL# PRESSURE GROUT <br /> {] � <br /> 'Other: Grout Specifications: Com" <br /> COMMENTS: 1 - ;,-.-.r A- r y <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE H�" MULTIPLE CASINGS?n YES 4NO WELL CASING DIA: _ <br /> 0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: []STEEL D PVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 41 TREMIE TYPE TO BE USED: []AUGERS 0 HOSE (� <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: I7 Yes (No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30) <br /> ASOIL BORING HAND AUGER GROUT SPECIFICATIONS:_ %�`�/" L.:-�^• f <br /> OTHER: 0 OTHER APPROX.BORING DEPTH Al` 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> U <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> 'COMMENTS: <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, Rule a Regulations,and all applicable California State Laws. <br /> _ _ TitlelCompany i el s(��� — <br /> Signed x <br /> —Date <br /> Print Name ' ` DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: <br /> WORK PLAN DATED: � rea �C�310 7::��' ZV <br /> DZ <br /> Application Accepted By Date Issued l <br /> Date_, <br /> Grout Inspection By <br /> ,o,Cp Date �' � C� Final inspection By <br /> Destruction Inspection By Date <br /> COMMENTS!CONDITIONS: <br /> .tom, M o w S <br /> ACCOUNTING ONLY: AID# CDS tf <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT l SE QUEST# INVOICE <br /> F; <br /> �� ll5D /�(L d G bZ SR# 00 3ooSo <br /> C-57 WC=WAIVER._ C-57 Letter of Authorization to Sign permit <br /> OC <br /> 1/25/02 <br />