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11/02/2004 08:55 <br />RDECOWED <br />NOV 0 3 2004 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />20946834333 <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 />(209) 4683449 <br />PAGE 02 <br />SITE <br />MITIGATION <br />UNIT IV <br />NON-REFUNDABLE pERM17 ISSUE <br />EX EXPIRES YEAR FROM D TE D <br />Application is hereby made to San JoagauineC�oun1 l 3 and the l Standards of San Joaquior instn County Env ro mthe work e ntal HealthlDepartm Depica6orl is artment, <br />in compliance with San <br />Joaquin County Development Title, Chapter Assessors N <br />1 ' <br />,} O Zip Parcel# <br />ARCA aeWi� CJ1't� I �Street C1+ LC.l-� City _ <br />WELL Location <br />�lL I� <br />jv <br />1�11%1Q Zip�Z(91[ Lic4 <br />Qi�_AddressC�RAyRl� <br />OPROPERTY Owner-cl 3Phone#c I - Le <br />larz� City <br />C-57 Contractorj <br />dressi Phone# �Lf ;50U 7 /y 0 U <br />Ad�'� E � v-tVl k IO% city i t' ias, n <br />Consultant /Sub Cntr w' .-- � Section lam' <br />�`, Township i Iii Range <br />GIS Coordinates: X <br />WORK TO BE PERFORMED: <br />a NEW WELL / BORING (CPT, GEOPROBE. HYDROPUNCH, HAND -AUGER, OTHER') <br />Q SOIL BORING # <br />n WELL # <br />COMMEN S: ' ^ I <br />XN���,'ln1 I a(A t , 'v v <br />p DESTRUCTION (choose type below) <br />0 OVER -BORE. DIAMETER <br />PRESSURE GROUT �, C <br />QROUT SPECIFICATIONS NERNT <br />TYPE OF WELL INSTALLATION TYPE D ANSTRUCTION BOREHOLE ECIFICOA IONTIPLE CASINGS MULTI-LEVEL WELL CASING DIA: <br />0 MONITORING 0 HOLLOW STEM TYPE OF CASING: a STEEL 0 PVC 0 OTHER: <br />a EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TREMIE "TYPE TO BE USED: - 0 AUGERS p HOSE <br />p VAPOR Q MUD ROTARY DEPTH OF GROUT SEAL <br />0 AIR SPARGE/ OZONE 0 PUSH POINT (GP or CPT) GROUT SEAL PUMPED: p Yes 0 No (NOTE: MAXIMUM FREE -FALL DEPTH IS 301 <br />ER GROUT SPECIFICATIONS <br />Q SOIL BORING 0HAND AUG0 BOLTED TRAFFIC BOX or p STOVE PIPE Jn, <br />,'OTHER: OTHER APPROX. BORING DEPTH <br />CONDUCTOR CASING PROPOSED (if YES, list specifications in comment section) <br />COMMENTS - -rem <br />ncccrrr- F16RINGS R QUIRE^ ACC SS AGREEMENT OR ENCROACHMENT PERMITS <br />48 WORKING HOURS NOTICE REQUIRED <br />I hereby certify that I have prepared this application and that the <br />work fon ill be done Laws. in accordance with San Joaquin <br />County Ordinances, Rules a d, gulattons, applicable pp <br />l/ Z, TitleJCompany C/ / {�Vti✓Id/1 !r t�C C / <br />Signed x <br />Print Name <br />SITE MAP IN UNIT IV FILE, ADDRESS. <br />DEPARTMENT Usk LJNLT <br />WORK PLAN DATED: <br />Date Issued <- Area <br />Application Accepted By Date U Final Inspection By Oate <br />// <br />Grout Inspection By_ <br />Date <br />Destruction Inspection By SL� ems• ��� rc G� P�I^�� <br />COMMENTS ! cONDITIONS: <br />IL <br />ACCOUNTING ONLY: AID# FAC# <br />- �RNJ REOUES INVOICE <br />PE CODES FEE INFO AMOUNT REMITTED CHECK# REC Q BY DATE �SR# �j� <br />9/30/Oi <br />-WAIVER C-57 Letter of Authorization to sign permit Encroachment or- <br />